1114976651 NPI number — CORAL SPRINGS AMBULATORY SURGERY CENTER LLC

Table of content: (NPI 1114976651)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114976651 NPI number — CORAL SPRINGS AMBULATORY SURGERY CENTER LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CORAL SPRINGS AMBULATORY 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:
6
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:
1114976651
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1725 UNIVERSITY DRIVE
Provider Second Line Business Mailing Address:
2ND FLOOR
Provider Business Mailing Address City Name:
CORAL SPRINGS
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33071
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
954-227-7760
Provider Business Mailing Address Fax Number:
954-227-9975

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1725 UNIVERSITY DRIVE
Provider Second Line Business Practice Location Address:
2ND FLOOR
Provider Business Practice Location Address City Name:
CORAL SPRINGS
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33071
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
954-227-7760
Provider Business Practice Location Address Fax Number:
954-227-9975
Provider Enumeration Date:
05/10/2006

Additional Information

Authorized Official

Authorized Official Last Name:
CLENDENIN
Authorized Official First Name:
PHILLIP
Authorized Official Middle Name:
A.
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
615-665-1283

Provider Taxonomy Codes

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

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

  • Identifier: SG013546 . This is a "VISTA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 2167675 . This is a "AETNA" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 63K . This is a "BC" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 070313300 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 261016 . This is a "AVMED" identifier . This identifiers is of the category "OTHER".
  • Identifier: 30734 . This is a "NEIGHBORHOOD" identifier . This identifiers is of the category "OTHER".
  • Identifier: 215430 . This is a "AMERIGROUP" identifier . This identifiers is of the category "OTHER".




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