Basic Information
| Provider Information | |||||||||
| NPI: | 1871694083 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DETROIT SURGICAL SPECIALIST, P.C. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 135 S PROSPECT ST | ||||||||
| Address2: | |||||||||
| City: | YPSILANTI | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481987914 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7345474900 | ||||||||
| FaxNumber: | 7345474901 | ||||||||
| Practice Location | |||||||||
| Address1: | 135 S PROSPECT ST | ||||||||
| Address2: | |||||||||
| City: | YPSILANTI | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481987914 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7345474900 | ||||||||
| FaxNumber: | 7345474901 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/26/2006 | ||||||||
| LastUpdateDate: | 06/29/2016 | ||||||||
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| AuthorizedOfficialLastName: | NUNN | ||||||||
| AuthorizedOfficialFirstName: | ANDRE | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3135474900 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | AN066667 | MI | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
No ID Information.