Provider Demographics
NPI:1215122437
Name:SURGICAL SPECIALTY GROUP LLC
Entity type:Organization
Organization Name:SURGICAL SPECIALTY GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:
Authorized Official - Last Name:GEORGESON
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:586-228-0798
Mailing Address - Street 1:16151 19 MILE RD
Mailing Address - Street 2:SUITE #301
Mailing Address - City:CLINTON TWP
Mailing Address - State:MI
Mailing Address - Zip Code:48038-1158
Mailing Address - Country:US
Mailing Address - Phone:586-228-0798
Mailing Address - Fax:586-228-1084
Practice Address - Street 1:16151 19 MILE RD
Practice Address - Street 2:SUITE #301
Practice Address - City:CLINTON TWP
Practice Address - State:MI
Practice Address - Zip Code:48038-1158
Practice Address - Country:US
Practice Address - Phone:586-228-0798
Practice Address - Fax:586-228-1084
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-11
Last Update Date:2007-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIAG009192208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0N92980Medicare PIN