NPIMap

Organization Active NPI

Sandusky Surgical PLLC

  • Clinic/Center
  • Sandusky, MI
National Provider Identifier
1093762742
Registry record updated Jan 3, 2008
On this page

Key facts

NPPES NPI Registry
Primary specialty
Clinic/CenterTaxonomy code 261Q00000X
License
4301084929 Issued in MI
Legal business name
SANDUSKY SURGICAL PLLC
Practice address
150 N Delaware St
Sandusky, MI 48471-1009
Phone
(810) 648-9670
Fax
(810) 648-9677
NPI assigned
May 28, 2006
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jan 3, 2008

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Khristine C Botezan, MD
Title
President
Phone
(810) 648-9670

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Clinic/Center 261Q00000X 4301084929 MI Primary

Addresses

Primary practice location

150 N Delaware St
Sandusky, MI 48471-1009

Mailing address

PO Box 191
Sandusky, MI 48471-0191
Phone (810) 648-9670

Other identifiers 1

IdentifierTypeStateIssuer
4700615MedicaidMI

National Provider Directory

National Provider Directory

Locations

150 N Delaware St
Sandusky, MI 48471
Phone (810) 648-6179

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1148774400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1199318400000",
    "number": "1093762742",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 191",
            "city": "SANDUSKY",
            "state": "MI",
            "postal_code": "484710191",
            "telephone_number": "810-648-9670",
            "fax_number": "810-648-9677"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "150 N DELAWARE ST",
            "city": "SANDUSKY",
            "state": "MI",
            "postal_code": "484711009",
            "telephone_number": "810-648-9670",
            "fax_number": "810-648-9677"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SANDUSKY SURGICAL PLLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-05-28",
        "last_updated": "2008-01-03",
        "status": "A",
        "authorized_official_last_name": "BOTEZAN",
        "authorized_official_first_name": "KHRISTINE",
        "authorized_official_middle_name": "C",
        "authorized_official_title_or_position": "PRESIDENT",
        "authorized_official_telephone_number": "810-648-9670",
        "authorized_official_credential": "MD"
    },
    "taxonomies": [
        {
            "code": "261Q00000X",
            "taxonomy_group": "",
            "desc": "Clinic/Center",
            "state": "MI",
            "license": "4301084929",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "4700615",
            "state": "MI"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Sandusky, MI

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jan 3, 2008; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.