1417050709 NPI number — COLUMBUS SURGERY CENTER, LLC

Table of content: (NPI 1417050709)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417050709 NPI number — COLUMBUS SURGERY CENTER, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COLUMBUS 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:
1417050709
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/03/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3772 43RD AVENUE
Provider Second Line Business Mailing Address:
SUITE B
Provider Business Mailing Address City Name:
COLUMBUS
Provider Business Mailing Address State Name:
NE
Provider Business Mailing Address Postal Code:
68601
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
402-562-8795
Provider Business Mailing Address Fax Number:
402-563-2765

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3772 43RD AVENUE
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
COLUMBUS
Provider Business Practice Location Address State Name:
NE
Provider Business Practice Location Address Postal Code:
68601
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
402-562-8795
Provider Business Practice Location Address Fax Number:
402-563-2765
Provider Enumeration Date:
09/05/2006

Additional Information

Authorized Official

Authorized Official Last Name:
DIEDRICHSEN
Authorized Official First Name:
PETER
Authorized Official Middle Name:
E
Authorized Official Title or Position:
OWNER/ GOVERNING BODY
Authorized Official Telephone Number:
402-562-8795

Provider Taxonomy Codes

  • Taxonomy code: 261QS0132X , registered in the state of NE ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 10025549900 , issued by the state of ( NE ) . This identifiers is of the category "MEDICAID".




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