Provider Demographics
NPI:1487834073
Name:MICHIANNA SURGICAL ASSOCIATES PC
Entity Type:Organization
Organization Name:MICHIANNA SURGICAL ASSOCIATES PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GODSON
Authorized Official - Middle Name:G
Authorized Official - Last Name:KOTIA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:269-651-7003
Mailing Address - Street 1:1904 E CHICAGO RD
Mailing Address - Street 2:
Mailing Address - City:STURGIS
Mailing Address - State:MI
Mailing Address - Zip Code:49091-8522
Mailing Address - Country:US
Mailing Address - Phone:269-651-7003
Mailing Address - Fax:269-651-8790
Practice Address - Street 1:1904 E CHICAGO RD
Practice Address - Street 2:
Practice Address - City:STURGIS
Practice Address - State:MI
Practice Address - Zip Code:49091-8522
Practice Address - Country:US
Practice Address - Phone:269-651-7003
Practice Address - Fax:269-651-8790
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-12
Last Update Date:2009-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301078341208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)Group - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI104342471Medicaid
MIN35760Medicare PIN