Provider Demographics
NPI:1689046070
Name:SOUTHGATE ALLIED ANESTHESIA PLLC
Entity Type:Organization
Organization Name:SOUTHGATE ALLIED ANESTHESIA PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMIN
Authorized Official - Prefix:
Authorized Official - First Name:ATIF
Authorized Official - Middle Name:
Authorized Official - Last Name:BAWAHAB
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:979-574-7109
Mailing Address - Street 1:PO BOX 2071
Mailing Address - Street 2:
Mailing Address - City:SOUTHGATE
Mailing Address - State:MI
Mailing Address - Zip Code:48195-4071
Mailing Address - Country:US
Mailing Address - Phone:313-263-5961
Mailing Address - Fax:313-263-5963
Practice Address - Street 1:13460 FORT ST
Practice Address - Street 2:
Practice Address - City:SOUTHGATE
Practice Address - State:MI
Practice Address - Zip Code:48195-1138
Practice Address - Country:US
Practice Address - Phone:313-263-5961
Practice Address - Fax:313-263-5963
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-24
Last Update Date:2015-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704090801367H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist AssistantGroup - Multi-Specialty