Basic Information
| Provider Information | |||||||||
| NPI: | 1487609475 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | AMERICAN ANESTHESIOLOGY OF MICHIGAN PC | ||||||||
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| OtherOrganizationName: | SOUTH OAKLAND ANESTHESIA ASSOCIATES, PC | ||||||||
| OtherOrganizationType: | 4 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1305 WALT WHITMAN RD STE 300 | ||||||||
| Address2: | |||||||||
| City: | MELVILLE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117474300 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5169453000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3601 W 13 MILE RD | ||||||||
| Address2: | |||||||||
| City: | ROYAL OAK | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480736712 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2488981905 | ||||||||
| FaxNumber: | 2488981032 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/24/2006 | ||||||||
| LastUpdateDate: | 03/03/2022 | ||||||||
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| AuthorizedOfficialLastName: | WALSH | ||||||||
| AuthorizedOfficialFirstName: | MATTHEW | ||||||||
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| AuthorizedOfficialTitleorPosition: | MEDICAL DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 8002433839 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 03/03/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 050F361920 | 01 | MI | BCBSM | OTHER |