Basic Information
| Provider Information | |||||||||
| NPI: | 1144382789 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SURGICAL SPECIALISTS OF ST. JOSEPH, P.C. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2990 NILES RD | ||||||||
| Address2: | |||||||||
| City: | SAINT JOSEPH | ||||||||
| State: | MI | ||||||||
| PostalCode: | 490858607 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2699833368 | ||||||||
| FaxNumber: | 2699832758 | ||||||||
| Practice Location | |||||||||
| Address1: | 2990 NILES RD | ||||||||
| Address2: | |||||||||
| City: | SAINT JOSEPH | ||||||||
| State: | MI | ||||||||
| PostalCode: | 490858607 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2699833368 | ||||||||
| FaxNumber: | 2699832758 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/13/2006 | ||||||||
| LastUpdateDate: | 07/20/2011 | ||||||||
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| AuthorizedOfficialLastName: | HASTINGS | ||||||||
| AuthorizedOfficialFirstName: | JACQUELYN | ||||||||
| AuthorizedOfficialMiddleName: | A. | ||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 2699833368 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 020A110340 | 01 | MI | BCBS GROUP | OTHER |