Provider Demographics
NPI:1194760280
Name:NORTHWEST CRITICAL CARE SURGEONS, PLLC
Entity type:Organization
Organization Name:NORTHWEST CRITICAL CARE SURGEONS, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ATWAL
Authorized Official - Middle Name:
Authorized Official - Last Name:MANDIP
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:248-353-0200
Mailing Address - Street 1:PO BOX 44047
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48244-0047
Mailing Address - Country:US
Mailing Address - Phone:248-543-8070
Mailing Address - Fax:248-543-9005
Practice Address - Street 1:27209 LAHSER RD
Practice Address - Street 2:SUITE 128
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48034-8401
Practice Address - Country:US
Practice Address - Phone:248-353-0200
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-20
Last Update Date:2011-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43010511422086S0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0102XAllopathic & Osteopathic PhysiciansSurgerySurgical Critical CareGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0P34250Medicare PIN