Basic Information
| Provider Information | |||||||||
| NPI: | 1780923128 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MACOMB ENDOSCOPY CENTER LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1701 SOUTH BLVD E | ||||||||
| Address2: | STE 300 | ||||||||
| City: | ROCHESTER HILLS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483076122 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2488449782 | ||||||||
| FaxNumber: | 5867268557 | ||||||||
| Practice Location | |||||||||
| Address1: | 48801 ROMEO PLANK RD | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | MACOMB | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480442165 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5867268423 | ||||||||
| FaxNumber: | 5867268557 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/05/2013 | ||||||||
| LastUpdateDate: | 09/28/2022 | ||||||||
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| AuthorizedOfficialLastName: | MICHALEK | ||||||||
| AuthorizedOfficialFirstName: | MARY | ||||||||
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| AuthorizedOfficialTitleorPosition: | FACILITY ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 5867268423 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 09/28/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA1903X | MI | Y | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
No ID Information.