Provider Demographics
NPI:1447222468
Name:MICHIGAN CENTER FOR ORTHOPEDIC SURGERY PLC
Entity Type:Organization
Organization Name:MICHIGAN CENTER FOR ORTHOPEDIC SURGERY PLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SHIVAJEE
Authorized Official - Middle Name:
Authorized Official - Last Name:NALLAMOTHU
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:248-620-2325
Mailing Address - Street 1:5701 BOW POINTE DR
Mailing Address - Street 2:STE 300
Mailing Address - City:CLARKSTON
Mailing Address - State:MI
Mailing Address - Zip Code:48346-3198
Mailing Address - Country:US
Mailing Address - Phone:248-620-2325
Mailing Address - Fax:248-620-2326
Practice Address - Street 1:5701 BOW POINTE DR
Practice Address - Street 2:STE 300
Practice Address - City:CLARKSTON
Practice Address - State:MI
Practice Address - Zip Code:48346-3198
Practice Address - Country:US
Practice Address - Phone:248-620-2325
Practice Address - Fax:248-620-2326
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-03
Last Update Date:2012-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0N96360Medicare PIN