Basic Information
| Provider Information | |||||||||
| NPI: | 1679508659 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WEST MICHIGAN SURGICAL SPECIALISTS PLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1045 GEZON PKWY SW | ||||||||
| Address2: | |||||||||
| City: | WYOMING | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495099542 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6164565311 | ||||||||
| FaxNumber: | 6164567955 | ||||||||
| Practice Location | |||||||||
| Address1: | 1045 GEZON PKWY SW | ||||||||
| Address2: | |||||||||
| City: | WYOMING | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495099542 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6164565311 | ||||||||
| FaxNumber: | 6164567955 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/11/2006 | ||||||||
| LastUpdateDate: | 01/05/2021 | ||||||||
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| AuthorizedOfficialLastName: | BORRESON | ||||||||
| AuthorizedOfficialFirstName: | DANIEL | ||||||||
| AuthorizedOfficialMiddleName: | K | ||||||||
| AuthorizedOfficialTitleorPosition: | M.D./PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 6164565311 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | 01/05/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | DB041912 | MI | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 0D16117 | 01 | MI | BCBS | OTHER |