Provider Demographics
NPI:1629079611
Name:NEWCO AMBULATORY SURGERY CENTER, LLP
Entity Type:Organization
Organization Name:NEWCO AMBULATORY SURGERY CENTER, LLP
Other - Org Name:LAKESHORE SURGERY CENTER, LLP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:P
Authorized Official - Last Name:CONNELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:810-989-7751
Mailing Address - Street 1:4190 24TH AVE
Mailing Address - Street 2:
Mailing Address - City:FORT GRATIOT
Mailing Address - State:MI
Mailing Address - Zip Code:48059-3882
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:810-989-7652
Practice Address - Street 1:4190 24TH AVE
Practice Address - Street 2:
Practice Address - City:FORT GRATIOT
Practice Address - State:MI
Practice Address - Zip Code:48059-3882
Practice Address - Country:US
Practice Address - Phone:810-989-7649
Practice Address - Fax:810-989-7652
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI746818261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
4563971OtherCIGNA
30036708OtherFIRST HEALTH
32463OtherHEALTH PLAN OF MICHIGAN
MI40221OtherBLUE CROSS BLUE SHIELD
40221OtherBLUE CARE NETWORK
139016OtherPREFERRED CHOICES
139016OtherCARE CHOICES
MI143728OtherGREAT LAKES HEALTH PLAN
MI40221OtherBLUE CROSS BLUE SHIELD
4563971OtherCIGNA
=========OtherPPOM
=========OtherAETNA
32463OtherHEALTH PLAN OF MICHIGAN