Provider Demographics
NPI:1982802203
Name:BEAUMONT WEST BLOOMFIELD ASC LLC
Entity type:Organization
Organization Name:BEAUMONT WEST BLOOMFIELD ASC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:T
Authorized Official - Last Name:FOX
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:248-213-3334
Mailing Address - Street 1:6900 ORCHARD LAKE ROAD
Mailing Address - Street 2:SUITE LL100
Mailing Address - City:WEST BLOOMFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48322
Mailing Address - Country:US
Mailing Address - Phone:248-406-2400
Mailing Address - Fax:248-406-2401
Practice Address - Street 1:6900 ORCHARD LAKE ROAD
Practice Address - Street 2:SUITE LL100
Practice Address - City:WEST BLOOMFIELD
Practice Address - State:MI
Practice Address - Zip Code:48322
Practice Address - Country:US
Practice Address - Phone:248-406-2400
Practice Address - Fax:248-406-2401
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-08
Last Update Date:2015-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI1010000081261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI23C0001106Medicare UPIN
MI23C000106Medicare Oscar/Certification