1255503553 NPI number — WILLOUGHBY SURGERY CENTER, LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255503553 NPI number — WILLOUGHBY SURGERY CENTER, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WILLOUGHBY SURGERY CENTER, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1255503553
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/20/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6025 COMMERCE CIR
Provider Second Line Business Mailing Address:
SUITE 1
Provider Business Mailing Address City Name:
WILLOUGHBY
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
44094-9668
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
440-585-2750
Provider Business Mailing Address Fax Number:
440-944-0868

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6025 COMMERCE CIR
Provider Second Line Business Practice Location Address:
SUITE 1
Provider Business Practice Location Address City Name:
WILLOUGHBY
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
44094-9668
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
440-585-2750
Provider Business Practice Location Address Fax Number:
440-944-0868
Provider Enumeration Date:
03/26/2008

Additional Information

Authorized Official

Authorized Official Last Name:
DEMANGONE
Authorized Official First Name:
DAVID
Authorized Official Middle Name:
A
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
440-944-1414

Provider Taxonomy Codes

  • Taxonomy code: 261QA1903X , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: P00829745 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 3137920 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".




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