Provider Demographics
NPI:1679605570
Name:SOUTHEAST MICHIGAN SURGICAL HOSPITAL, LLC
Entity Type:Organization
Organization Name:SOUTHEAST MICHIGAN SURGICAL HOSPITAL, LLC
Other - Org Name:SOUTHEAST MICHIGAN SURGICAL HOSPITAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:NADIR
Authorized Official - Middle Name:
Authorized Official - Last Name:IJAZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:810-275-9371
Mailing Address - Street 1:21230 DEQUINDRE RD
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48091-2279
Mailing Address - Country:US
Mailing Address - Phone:586-427-1000
Mailing Address - Fax:586-759-0237
Practice Address - Street 1:21230 DEQUINDRE RD
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48091-2279
Practice Address - Country:US
Practice Address - Phone:586-427-1000
Practice Address - Fax:586-759-0237
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-09
Last Update Date:2019-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0E01458OtherBCBS MEDICAL DOCTORS
MI2619390Medicaid
MI0E01458OtherBCBS PROVIDER ID#
MI2619390Medicaid
MI0N79780Medicare ID - Type UnspecifiedMEDICAL DOCTORS