Basic Information
| Provider Information | |||||||||
| NPI: | 1942393475 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NORTH OAKLAND ASC LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 461 WEST HURON ST | ||||||||
| Address2: | SUITE 206 | ||||||||
| City: | PONTIAC | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483410000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2488577583 | ||||||||
| FaxNumber: | 2488577588 | ||||||||
| Practice Location | |||||||||
| Address1: | 1305 NORTH OAKLAND BLVD | ||||||||
| Address2: | |||||||||
| City: | WATERFORD | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483271547 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2486665552 | ||||||||
| FaxNumber: | 2486665549 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/02/2006 | ||||||||
| LastUpdateDate: | 03/16/2011 | ||||||||
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| AuthorizedOfficialLastName: | DERUBEIS | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 2488577583 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | OAKLAND PHYSICIANS MEDICAL CENTER | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA1903X | 636823 | MI | Y | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
ID Information
| ID | Type | State | Issuer | Description | 141676 | 01 | MI | CARE CHOICES | OTHER | 17412 | 01 | MI | MCARE | OTHER | 40347 | 01 | MI | BCBS - FACILITY | OTHER | 490F32891 | 01 | MI | BCBS - PROFESSIONAL | OTHER | B0100 | 01 | MI | BCN | OTHER |