Basic Information
| Provider Information | |||||||||
| NPI: | 1093749376 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | UROLOGY SURGERY CENTER,LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 139 SUMMERPLACE DR | ||||||||
| Address2: | |||||||||
| City: | WEST COLUMBIA | ||||||||
| State: | SC | ||||||||
| PostalCode: | 29169 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8037969968 | ||||||||
| FaxNumber: | 8037910376 | ||||||||
| Practice Location | |||||||||
| Address1: | 139 SUMMERPLACE DR | ||||||||
| Address2: | |||||||||
| City: | WEST COLUMBIA | ||||||||
| State: | SC | ||||||||
| PostalCode: | 29169 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8037969968 | ||||||||
| FaxNumber: | 8037910376 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/10/2006 | ||||||||
| LastUpdateDate: | 03/28/2013 | ||||||||
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| AuthorizedOfficialLastName: | LAMB | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | H | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 8037969968 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA1903X | 261QA1903X | SC | Y | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
ID Information
| ID | Type | State | Issuer | Description | ASC022 | 05 | SC | MEDICAID |