Provider Demographics
NPI:1588631832
Name:SURGICAL SERVICES OF MICHIGAN, LLC
Entity Type:Organization
Organization Name:SURGICAL SERVICES OF MICHIGAN, LLC
Other - Org Name:BLAKE WOODS MEDICAL PARK
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MRS
Authorized Official - First Name:BROOKE
Authorized Official - Middle Name:A
Authorized Official - Last Name:DAY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:517-787-2906
Mailing Address - Street 1:2775 BLAKE ROAD
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49201-8838
Mailing Address - Country:US
Mailing Address - Phone:517-787-2906
Mailing Address - Fax:517-787-3039
Practice Address - Street 1:2775 BLAKE ROAD
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49201-8838
Practice Address - Country:US
Practice Address - Phone:517-787-2906
Practice Address - Fax:517-787-3039
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-07
Last Update Date:2011-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI490003502OtherRAILROAD MEDICARE
MI40366OtherBCBSM FACILITY PIN
MI490C870000OtherBCBSM PROFESSIONAL PIN
MI40366OtherBLUE CARE NETWORK PIN
MI490C870000OtherBCBSM PROFESSIONAL PIN