Provider Demographics
NPI:1891780417
Name:PHYSICIAN ANESTHESIA SERVICE PC
Entity Type:Organization
Organization Name:PHYSICIAN ANESTHESIA SERVICE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED OFFICIAL
Authorized Official - Prefix:MR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:COOK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:800-891-2351
Mailing Address - Street 1:DEPT 78178 PO BOX 78000
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48278-0178
Mailing Address - Country:US
Mailing Address - Phone:800-891-2351
Mailing Address - Fax:800-891-2351
Practice Address - Street 1:826 W KING ST
Practice Address - Street 2:
Practice Address - City:OWOSSO
Practice Address - State:MI
Practice Address - Zip Code:48867-2120
Practice Address - Country:US
Practice Address - Phone:989-723-5211
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-20
Last Update Date:2020-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIOC37630Medicare ID - Type Unspecified