Provider Demographics
NPI:1700984200
Name:NORTHEAST SURGICAL GROUP PC
Entity Type:Organization
Organization Name:NORTHEAST SURGICAL GROUP PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:HENRY
Authorized Official - Last Name:MCQUISTON
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:586-228-0550
Mailing Address - Street 1:17375 HALL RD
Mailing Address - Street 2:
Mailing Address - City:MACOMB
Mailing Address - State:MI
Mailing Address - Zip Code:48044-4060
Mailing Address - Country:US
Mailing Address - Phone:586-228-0550
Mailing Address - Fax:586-228-8830
Practice Address - Street 1:17375 HALL RD
Practice Address - Street 2:
Practice Address - City:MACOMB
Practice Address - State:MI
Practice Address - Zip Code:48044-4060
Practice Address - Country:US
Practice Address - Phone:586-228-0550
Practice Address - Fax:586-228-8830
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2015-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0N87470Medicare PIN