Provider Demographics
NPI:1952576431
Name:NORTHEAST SURGICAL SPECIALISTS, PC
Entity Type:Organization
Organization Name:NORTHEAST SURGICAL SPECIALISTS, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PETER
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:KOWYNIA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:586-212-0606
Mailing Address - Street 1:43211 DALCOMA DR
Mailing Address - Street 2:SUIT 4
Mailing Address - City:CLINTON TWP
Mailing Address - State:MI
Mailing Address - Zip Code:48038-6309
Mailing Address - Country:US
Mailing Address - Phone:586-286-8800
Mailing Address - Fax:586-286-8068
Practice Address - Street 1:43211 DALCOMA DR
Practice Address - Street 2:SUITE 4
Practice Address - City:CLINTON TWP
Practice Address - State:MI
Practice Address - Zip Code:48038-6309
Practice Address - Country:US
Practice Address - Phone:586-286-8800
Practice Address - Fax:586-286-8068
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-25
Last Update Date:2013-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301051240208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI02 0502600OtherBLUE CROSS BLUE SHIELD OF MICHIGAN
MI102873117Medicaid
MI02 0502600OtherBLUE CROSS BLUE SHIELD OF MICHIGAN
MIF22193Medicare UPIN