Provider Demographics
NPI:1588756555
Name:SURGEONS OF MICHIGAN PC
Entity type:Organization
Organization Name:SURGEONS OF MICHIGAN PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:
Authorized Official - Last Name:BOLTON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:248-335-9449
Mailing Address - Street 1:44555 WOODWARD AVE
Mailing Address - Street 2:SUITE 201
Mailing Address - City:PONTIAC
Mailing Address - State:MI
Mailing Address - Zip Code:48341-5031
Mailing Address - Country:US
Mailing Address - Phone:248-335-9449
Mailing Address - Fax:248-858-3933
Practice Address - Street 1:44555 WOODWARD AVE
Practice Address - Street 2:SUITE 201
Practice Address - City:PONTIAC
Practice Address - State:MI
Practice Address - Zip Code:48341-5031
Practice Address - Country:US
Practice Address - Phone:248-335-9449
Practice Address - Fax:248-858-3933
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-28
Last Update Date:2008-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301038308208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0206308521OtherBLUE CROSS BLUE SHIELD
MI0P17080Medicare ID - Type Unspecified
MI0206308521OtherBLUE CROSS BLUE SHIELD