Provider Demographics
NPI:1104867910
Name:COMMUNITY ORTHOPEDIC SURGERY PC
Entity type:Organization
Organization Name:COMMUNITY ORTHOPEDIC SURGERY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SANDRA
Authorized Official - Middle Name:D
Authorized Official - Last Name:BOLTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:734-712-0635
Mailing Address - Street 1:5315 ELLIOTT DR
Mailing Address - Street 2:SUITE 202
Mailing Address - City:YPSILANTI
Mailing Address - State:MI
Mailing Address - Zip Code:48197-8634
Mailing Address - Country:US
Mailing Address - Phone:734-712-0600
Mailing Address - Fax:734-712-0522
Practice Address - Street 1:5315 ELLIOTT DR
Practice Address - Street 2:SUITE 202
Practice Address - City:YPSILANTI
Practice Address - State:MI
Practice Address - Zip Code:48197-8634
Practice Address - Country:US
Practice Address - Phone:734-712-0600
Practice Address - Fax:734-712-0522
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-10
Last Update Date:2008-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
174400000X
MIRN043612207XS0106X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207XS0106XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryHand SurgeryGroup - Multi-Specialty
No174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI540D711950OtherBCBSM DME
MI540H115470OtherBCBSM DME
MI0P33610Medicare PIN
MIH51124Medicare UPIN
MIE88283Medicare UPIN
MIE25855Medicare UPIN
MIF04727Medicare UPIN
MI540D711950OtherBCBSM DME
MIA76100Medicare UPIN
MI540H115470OtherBCBSM DME
MIB45942Medicare UPIN
MIG13675Medicare UPIN