1528077658 NPI number — PRINCE WILLIAM AMBULATORY SURGERY CENTER, LLC

Table of content: (NPI 1528077658)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1528077658 NPI number — PRINCE WILLIAM AMBULATORY SURGERY CENTER, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PRINCE WILLIAM 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:
PRINCE WILLIAM SURGERY CENTER
Provider Other Organization Name Type Code:
5
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:
1528077658
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/29/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8644 SUDLEY RD
Provider Second Line Business Mailing Address:
SUITE 201
Provider Business Mailing Address City Name:
MANASSAS
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
20110-4417
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
703-369-8525
Provider Business Mailing Address Fax Number:
571-229-1533

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8644 SUDLEY RD
Provider Second Line Business Practice Location Address:
SUITE 201
Provider Business Practice Location Address City Name:
MANASSAS
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
20110-4417
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
703-369-8525
Provider Business Practice Location Address Fax Number:
571-229-1533
Provider Enumeration Date:
08/07/2006

Additional Information

Authorized Official

Authorized Official Last Name:
O'CONNOR
Authorized Official First Name:
KRISTEN
Authorized Official Middle Name:
Authorized Official Title or Position:
OFFICER / AUTHORIZED OFFICIAL
Authorized Official Telephone Number:
615-376-7315

Provider Taxonomy Codes

  • Taxonomy code: 261QA1903X , with the licence number:  OH695 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 186080 . This is a "ANTHEM" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 9731258 . This is a "CIGNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 2142411 . This is a "MAMSI/UHC" identifier . This identifiers is of the category "OTHER".
  • Identifier: 010274656 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 186080 . This is a "ANTHEM HEALTHKEEPERS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 2142411 . This is a "MDIPA/OPTIMUM CHOICE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 2579620 . This is a "UHC" identifier . This identifiers is of the category "OTHER".




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