1619998523 NPI number — UPSTATE 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 1619998523 NPI number — UPSTATE SURGERY CENTER, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
UPSTATE 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:
1619998523
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/03/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
12670 CREEKSIDE LN STE 401
Provider Second Line Business Mailing Address:
SUITE 401
Provider Business Mailing Address City Name:
FORT MYERS
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33919-3370
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
239-274-1000
Provider Business Mailing Address Fax Number:
239-274-1001

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10 ENTERPRISE BLVD
Provider Second Line Business Practice Location Address:
SUITE 104
Provider Business Practice Location Address City Name:
GREENVILLE
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29615-6301
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
864-458-7141
Provider Business Practice Location Address Fax Number:
864-676-9116
Provider Enumeration Date:
07/23/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MCCULLOCH
Authorized Official First Name:
RAYMOND
Authorized Official Middle Name:
Authorized Official Title or Position:
CONTROLLER
Authorized Official Telephone Number:
864-282-4910

Provider Taxonomy Codes

  • Taxonomy code: 261QA1903X , with the licence number:  ASF-050 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: ASC028 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".




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