Provider Demographics
NPI:1518957729
Name:NORTHWEST MICHIGAN SURGERY CENTER LLC
Entity Type:Organization
Organization Name:NORTHWEST MICHIGAN SURGERY CENTER LLC
Other - Org Name:COPPER RIDGE SURGERY CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:TINA
Authorized Official - Middle Name:L
Authorized Official - Last Name:PIOTROWSKI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:231-392-8950
Mailing Address - Street 1:4100 PARK FOREST DRIVE
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49684-6725
Mailing Address - Country:US
Mailing Address - Phone:231-392-8900
Mailing Address - Fax:231-392-8973
Practice Address - Street 1:4100 PARK FOREST DRIVE
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684-6725
Practice Address - Country:US
Practice Address - Phone:231-392-8900
Practice Address - Fax:231-392-8973
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-27
Last Update Date:2019-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI286173261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI38217OtherPRIORITY HEALTH
MI40340OtherBLUE CROSS BLUE SHIELD MI
MIP118278OtherBLUE CARE NETWORK MI
KY487354900OtherUS DEPT OF LABOR
MN104539OtherHEALTH PARTNERS
MI40340OtherBLUE CROSS BLUE SHIELD
MIP118278OtherBLUE CARE NETWORK
GA00099448OtherRAILROAD MEDICARE
MI487354900OtherASR CORP
MI487354900OtherASR CORP
MIP118278OtherBLUE CARE NETWORK MI