Provider Demographics
NPI:1689662926
Name:MIDLAND SURGICAL GROUP PC
Entity Type:Organization
Organization Name:MIDLAND SURGICAL GROUP PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ELLSWORTH
Authorized Official - Middle Name:EMIL
Authorized Official - Last Name:LUDWIG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:989-631-1221
Mailing Address - Street 1:4007 ORCHARD DR
Mailing Address - Street 2:SUITE 2003
Mailing Address - City:MIDLAND
Mailing Address - State:MI
Mailing Address - Zip Code:48640-6190
Mailing Address - Country:US
Mailing Address - Phone:989-631-1221
Mailing Address - Fax:989-631-6686
Practice Address - Street 1:4007 ORCHARD DR
Practice Address - Street 2:SUITE 2003
Practice Address - City:MIDLAND
Practice Address - State:MI
Practice Address - Zip Code:48640-6187
Practice Address - Country:US
Practice Address - Phone:989-631-1221
Practice Address - Fax:989-631-6686
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-11
Last Update Date:2010-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI040961208600000X
MI047857208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI020E66017OtherBCBS
0E66017Medicare ID - Type Unspecified