Provider Demographics
NPI:1558442830
Name:SOUTHEASTERN MICHIGAN SERVICES, INC.
Entity Type:Organization
Organization Name:SOUTHEASTERN MICHIGAN SERVICES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO, PRES.,CHAIRMAN, SEC., TREAS.
Authorized Official - Prefix:MR
Authorized Official - First Name:ADAM
Authorized Official - Middle Name:HEALY
Authorized Official - Last Name:MAHAR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:248-979-2001
Mailing Address - Street 1:17755 WINSTON ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48219-3078
Mailing Address - Country:US
Mailing Address - Phone:248-979-2001
Mailing Address - Fax:313-977-9750
Practice Address - Street 1:17755 WINSTON ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48219-3078
Practice Address - Country:US
Practice Address - Phone:248-979-2001
Practice Address - Fax:313-977-9750
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-17
Last Update Date:2008-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0M09800Medicare ID - Type UnspecifiedPROVIDER CODE FOR CORPOR