Provider Demographics
NPI:1760603484
Name:SURGICAL SPECIALIST OF MICHIGAN PC
Entity Type:Organization
Organization Name:SURGICAL SPECIALIST OF MICHIGAN PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:AKASH
Authorized Official - Middle Name:RUSHIKUMAR
Authorized Official - Last Name:SHETH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:586-771-8900
Mailing Address - Street 1:21000 E 12 MILE RD
Mailing Address - Street 2:SUITE 112
Mailing Address - City:SAINT CLAIR SHORES
Mailing Address - State:MI
Mailing Address - Zip Code:48081-1116
Mailing Address - Country:US
Mailing Address - Phone:586-771-8900
Mailing Address - Fax:586-771-8901
Practice Address - Street 1:21000 E 12 MILE RD
Practice Address - Street 2:SUITE 112
Practice Address - City:SAINT CLAIR SHORES
Practice Address - State:MI
Practice Address - Zip Code:48081-1116
Practice Address - Country:US
Practice Address - Phone:586-771-8900
Practice Address - Fax:586-771-8901
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-01
Last Update Date:2011-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301057707174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI453676010Medicaid
MI453674210Medicaid
MIG93036Medicare UPIN
MIN77200001Medicare ID - Type UnspecifiedARS
MI453676010Medicaid
MIN77200002Medicare ID - Type UnspecifiedDRS