Provider Demographics
NPI:1194812651
Name:LONG LAKE ANESTHESIOLOGY CONSULTANTS, PLC
Entity type:Organization
Organization Name:LONG LAKE ANESTHESIOLOGY CONSULTANTS, PLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:
Authorized Official - Last Name:SIWEK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:248-835-9829
Mailing Address - Street 1:4550 INVESTMENT DR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48098-6363
Mailing Address - Country:US
Mailing Address - Phone:800-581-9044
Mailing Address - Fax:248-856-3357
Practice Address - Street 1:4550 INVESTMENT DR
Practice Address - Street 2:SUITE 100
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48098-6363
Practice Address - Country:US
Practice Address - Phone:800-581-9044
Practice Address - Fax:248-856-3357
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-06
Last Update Date:2023-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI050F301710OtherBCBSM
MI0N84210Medicare PIN