Provider Demographics
NPI:1538339098
Name:MOUNTAIN WEST SURGICAL ASSOCIATES, PROF. LLC
Entity type:Organization
Organization Name:MOUNTAIN WEST SURGICAL ASSOCIATES, PROF. LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBER
Authorized Official - Middle Name:
Authorized Official - Last Name:GROSS
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:734-458-4492
Mailing Address - Street 1:6255 INKSTER RD
Mailing Address - Street 2:SUITE 204
Mailing Address - City:GARDEN CITY
Mailing Address - State:MI
Mailing Address - Zip Code:48135-2577
Mailing Address - Country:US
Mailing Address - Phone:734-458-4492
Mailing Address - Fax:734-458-7538
Practice Address - Street 1:11600 15 MILE RD
Practice Address - Street 2:SUITE 1
Practice Address - City:STERLING HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48312-5100
Practice Address - Country:US
Practice Address - Phone:586-978-2951
Practice Address - Fax:586-979-8758
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-11
Last Update Date:2013-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIRG012468208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1427143387Medicaid
MI0255011765OtherBCBS
MI0P22830Medicare PIN