Basic Information
| Provider Information | |||||||||
| NPI: | 1972544781 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ANESTHESIA SERVICES, PC GRACE | ||||||||
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| Mailing Information | |||||||||
| Address1: | P O BOX 1123 | ||||||||
| Address2: | 255 W MICHIGAN AVE | ||||||||
| City: | JACKSON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 492041123 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5177876440 | ||||||||
| FaxNumber: | 5177874146 | ||||||||
| Practice Location | |||||||||
| Address1: | 6071 W OUTER DR | ||||||||
| Address2: | |||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482352624 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3139663300 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/10/2006 | ||||||||
| LastUpdateDate: | 08/15/2011 | ||||||||
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| AuthorizedOfficialLastName: | FULEIHAN | ||||||||
| AuthorizedOfficialFirstName: | SAMIR | ||||||||
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| AuthorizedOfficialTitleorPosition: | AUTHORIZED REPRESENTATIVE | ||||||||
| AuthorizedOfficialTelephone: | 3139663300 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | Y | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Specialist |
No ID Information.