Basic Information
| Provider Information | |||||||||
| NPI: | 1629075106 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MICHIGAN ENDOSCOPY CENTER LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2500 YORK RD STE 300 | ||||||||
| Address2: | |||||||||
| City: | JAMISON | ||||||||
| State: | PA | ||||||||
| PostalCode: | 189291098 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2155899024 | ||||||||
| FaxNumber: | 8337056301 | ||||||||
| Practice Location | |||||||||
| Address1: | 30055 NORTHWESTERN HWY | ||||||||
| Address2: | SUITE L-60 | ||||||||
| City: | FARMINGTON HILLS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483343230 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2488656555 | ||||||||
| FaxNumber: | 2488656554 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/30/2005 | ||||||||
| LastUpdateDate: | 04/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | HOHLFELD | ||||||||
| AuthorizedOfficialFirstName: | SHARON | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | CO-TREASURER | ||||||||
| AuthorizedOfficialTelephone: | 2155899024 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 04/22/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA1903X | Y | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
ID Information
| ID | Type | State | Issuer | Description | 23-C0001045 | 01 | MEDICARE ASC NUMBER | OTHER | 23D1006055 | 01 | CLIA CERTIFICATE | OTHER | 23389 | 01 | AAAHC ACCREDITATION | OTHER | 40373 | 01 | MI | BCBSMI | OTHER | 010473 | 01 | MI | CERTIFICATE OF NEED | OTHER | 636910 | 01 | MI | STATE LICENESE | OTHER |