Basic Information
| Provider Information | |||||||||
| NPI: | 1255590766 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MACOMB ORTHOPEDIC SURGEONS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3607 OLD CONEJO RD | ||||||||
| Address2: | |||||||||
| City: | THOUSAND OAKS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 913202123 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 11900 E 12 MILE RD | ||||||||
| Address2: | SUITE 110 | ||||||||
| City: | WARREN | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480933400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5865827070 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/09/2008 | ||||||||
| LastUpdateDate: | 06/09/2008 | ||||||||
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| AuthorizedOfficialLastName: | MENDELSON | ||||||||
| AuthorizedOfficialFirstName: | STEPHEN | ||||||||
| AuthorizedOfficialMiddleName: | DOUGLAS | ||||||||
| AuthorizedOfficialTitleorPosition: | PHYSICIAN | ||||||||
| AuthorizedOfficialTelephone: | 5865827070 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332900000X | BM6782646 | MI | Y | Suppliers | Non-Pharmacy Dispensing Site |
No ID Information.