Provider Demographics
NPI:1750411856
Name:SOUTHEAST MICHIGAN SURGICAL HOSPITAL, LLC
Entity type:Organization
Organization Name:SOUTHEAST MICHIGAN SURGICAL HOSPITAL, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:ROBIN
Authorized Official - Middle Name:
Authorized Official - Last Name:COLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:810-275-9333
Mailing Address - Street 1:21230 DEQUINDRE RD
Mailing Address - Street 2:SOUTHEAST MICHIGAN SURGICAL HOSPITAL
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48091
Mailing Address - Country:US
Mailing Address - Phone:586-427-1000
Mailing Address - Fax:586-759-0237
Practice Address - Street 1:21230 DEQUINDRE RD
Practice Address - Street 2:SOUTHEAST MICHIGAN SURGICAL HOSPITAL
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48091
Practice Address - Country:US
Practice Address - Phone:586-427-1000
Practice Address - Fax:586-759-0237
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-07
Last Update Date:2024-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5677490001332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5677490001OtherBCBS DMERC PROVIDER #
MI5677490001OtherBCBS DMERC PROVIDER #