Provider Demographics
NPI:1962402354
Name:SOUTHEAST MICHIGAN SURGICAL HOSPITAL, LLC
Entity type:Organization
Organization Name:SOUTHEAST MICHIGAN SURGICAL HOSPITAL, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:NADIR
Authorized Official - Middle Name:
Authorized Official - Last Name:IJAZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:810-275-9371
Mailing Address - Street 1:21230 DEQUINDRE RD
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48091-2279
Mailing Address - Country:US
Mailing Address - Phone:586-427-1000
Mailing Address - Fax:586-759-0237
Practice Address - Street 1:21230 DEQUINDRE RD
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48091-2279
Practice Address - Country:US
Practice Address - Phone:586-427-1000
Practice Address - Fax:586-759-0237
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-28
Last Update Date:2025-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
273R00000X
MI500100282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital
No273R00000XHospital UnitsPsychiatric Unit
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI00297OtherBCBS PROVIDER ID #
MI404554179Medicaid
MI00947OtherCAPE MEDICAL PROV ID#
MI404554179Medicaid