Basic Information
| Provider Information | |||||||||
| NPI: | 1114976651 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CORAL SPRINGS AMBULATORY SURGERY CENTER LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | CORAL SPRINGS SURGICAL CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1725 UNIVERSITY DRIVE | ||||||||
| Address2: | 2ND FLOOR | ||||||||
| City: | CORAL SPRINGS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 33071 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9542277760 | ||||||||
| FaxNumber: | 9542279975 | ||||||||
| Practice Location | |||||||||
| Address1: | 1725 UNIVERSITY DRIVE | ||||||||
| Address2: | 2ND FLOOR | ||||||||
| City: | CORAL SPRINGS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 33071 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9542277760 | ||||||||
| FaxNumber: | 9542279975 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/10/2006 | ||||||||
| LastUpdateDate: | 04/02/2014 | ||||||||
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| AuthorizedOfficialLastName: | CLENDENIN | ||||||||
| AuthorizedOfficialFirstName: | PHILLIP | ||||||||
| AuthorizedOfficialMiddleName: | A. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 6156651283 | ||||||||
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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 | Y | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
ID Information
| ID | Type | State | Issuer | Description | SG013546 | 01 | VISTA | OTHER | 2167675 | 01 | FL | AETNA | OTHER | 63K | 01 | FL | BC | OTHER | 070313300 | 05 | FL | MEDICAID | 261016 | 01 | AVMED | OTHER | 30734 | 01 | NEIGHBORHOOD | OTHER | 215430 | 01 | AMERIGROUP | OTHER |