Provider Demographics
NPI:1619077211
Name:MICHIGAN INSTITUTE FOR ADVANCED SURGERY CENTER, LLC
Entity Type:Organization
Organization Name:MICHIGAN INSTITUTE FOR ADVANCED SURGERY CENTER, LLC
Other - Org Name:MICHIGAN INSTITUTE FOR ADVANCED SURGERY CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:DEBORAH
Authorized Official - Middle Name:
Authorized Official - Last Name:OTENBAKER
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:248-693-7954
Mailing Address - Street 1:1375 S LAPEER ROAD
Mailing Address - Street 2:SUITE 109
Mailing Address - City:LAKE ORION
Mailing Address - State:MI
Mailing Address - Zip Code:48360
Mailing Address - Country:US
Mailing Address - Phone:248-693-7950
Mailing Address - Fax:248-693-2658
Practice Address - Street 1:1375 S LAPEER ROAD
Practice Address - Street 2:SUITE 109
Practice Address - City:LAKE ORION
Practice Address - State:MI
Practice Address - Zip Code:48360
Practice Address - Country:US
Practice Address - Phone:248-693-7950
Practice Address - Fax:248-693-2658
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-24
Last Update Date:2022-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI1010000067261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical