Basic Information
| Provider Information | |||||||||
| NPI: | 1104850312 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MONTEREY PENINSULA SURGERY CENTER LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 966 CASS ST STE 150 | ||||||||
| Address2: | |||||||||
| City: | MONTEREY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 939404522 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8313722169 | ||||||||
| FaxNumber: | 8313726323 | ||||||||
| Practice Location | |||||||||
| Address1: | 966 CASS ST STE 150 | ||||||||
| Address2: | |||||||||
| City: | MONTEREY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 939404522 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8313722169 | ||||||||
| FaxNumber: | 8313726323 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/11/2006 | ||||||||
| LastUpdateDate: | 01/20/2009 | ||||||||
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| AuthorizedOfficialLastName: | WILSON | ||||||||
| AuthorizedOfficialFirstName: | THOMAS | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | MANAGING DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 8313722169 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA1903X | 070000398 | CA | Y | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
ID Information
| ID | Type | State | Issuer | Description | SUR01028G | 05 | CA | MEDICAID |