Provider Demographics
NPI:1497119689
Name:SOUTH EASTERN MICHIGAN COLON & RECTAL SURGERY
Entity Type:Organization
Organization Name:SOUTH EASTERN MICHIGAN COLON & RECTAL SURGERY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ADEWUNMI
Authorized Official - Middle Name:
Authorized Official - Last Name:ADEYEMO
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:743-722-6300
Mailing Address - Street 1:3106 S WAYNE RD
Mailing Address - Street 2:
Mailing Address - City:WAYNE
Mailing Address - State:MI
Mailing Address - Zip Code:48184-1221
Mailing Address - Country:US
Mailing Address - Phone:734-722-1063
Mailing Address - Fax:734-722-4815
Practice Address - Street 1:3106 S WAYNE RD
Practice Address - Street 2:
Practice Address - City:WAYNE
Practice Address - State:MI
Practice Address - Zip Code:48184-1221
Practice Address - Country:US
Practice Address - Phone:734-722-1063
Practice Address - Fax:734-722-4815
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-13
Last Update Date:2020-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1497119689Medicaid