Provider Demographics
NPI:1316939952
Name:MICHIGAN SURGERY SPECIALISTS, P.C.
Entity type:Organization
Organization Name:MICHIGAN SURGERY SPECIALISTS, P.C.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MICHELE
Authorized Official - Middle Name:
Authorized Official - Last Name:KUDLOR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:586-459-5592
Mailing Address - Street 1:31201 CHICAGO RD S STE C302
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48093-5553
Mailing Address - Country:US
Mailing Address - Phone:586-582-0864
Mailing Address - Fax:586-582-0964
Practice Address - Street 1:11012 THIRTEEN MILE ROAD
Practice Address - Street 2:SUITE 111
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48093
Practice Address - Country:US
Practice Address - Phone:586-558-8470
Practice Address - Fax:586-558-8481
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MICHIGAN SURGERY SPECIALISTS, P.C.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-08-19
Last Update Date:2025-03-26
Deactivation Date:2008-07-10
Deactivation Code:
Reactivation Date:2008-11-17
Provider Licenses
StateLicense IDTaxonomies
MI43010460612085R0202X, 2471C3401X
2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Multi-Specialty
No2471C3401XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistComputed TomographyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI300E017160OtherBCBS PIN NUMBER
53317OtherRADIATION MACHINE REGISTR
MI0E06376Medicare PIN