Provider Demographics
NPI:1467491407
Name:DEARBORN SURGERY CENTER, LLC
Entity Type:Organization
Organization Name:DEARBORN SURGERY CENTER, LLC
Other - Org Name:DEARBORN SURGERY CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BOARD MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:BARRY
Authorized Official - Middle Name:M
Authorized Official - Last Name:CULLEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:313-982-3040
Mailing Address - Street 1:18100 OAKWOOD BLVD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48124-4071
Mailing Address - Country:US
Mailing Address - Phone:313-253-2000
Mailing Address - Fax:313-253-2004
Practice Address - Street 1:18100 OAKWOOD BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48124-4071
Practice Address - Country:US
Practice Address - Phone:313-253-2000
Practice Address - Fax:313-253-2004
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-05
Last Update Date:2009-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI826846261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI23C0001059Medicare ID - Type UnspecifiedPROVIDER NUMBER
MI0P17750Medicare UPIN