Provider Demographics
NPI:1659400513
Name:SURGICAL SPECIALIST PC
Entity Type:Organization
Organization Name:SURGICAL SPECIALIST PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:GILBERT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:810-664-4100
Mailing Address - Street 1:844 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LAPEER
Mailing Address - State:MI
Mailing Address - Zip Code:48446-3027
Mailing Address - Country:US
Mailing Address - Phone:810-664-4100
Mailing Address - Fax:810-664-9250
Practice Address - Street 1:844 S MAIN ST
Practice Address - Street 2:
Practice Address - City:LAPEER
Practice Address - State:MI
Practice Address - Zip Code:48446-3027
Practice Address - Country:US
Practice Address - Phone:810-664-4100
Practice Address - Fax:810-664-9250
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-05
Last Update Date:2013-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MICL4629OtherRAILROAD MEDICARE
MICL4629OtherRAILROAD MEDICARE