Basic Information
| Provider Information | |||||||||
| NPI: | 1144259870 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BLACKHAWK SURGERY CENTER, A MEDICAL CORP. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11999 SAN VICENTE BL. | ||||||||
| Address2: | # 440 | ||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 90049 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3104403131 | ||||||||
| FaxNumber: | 3104729582 | ||||||||
| Practice Location | |||||||||
| Address1: | 3601 BLACKHAWK PLAZA CIRCLE | ||||||||
| Address2: | |||||||||
| City: | DANVILLE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 94506 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9257365757 | ||||||||
| FaxNumber: | 9257365763 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/03/2006 | ||||||||
| LastUpdateDate: | 10/31/2007 | ||||||||
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| AuthorizedOfficialLastName: | RONAN | ||||||||
| AuthorizedOfficialFirstName: | STEPHEN | ||||||||
| AuthorizedOfficialMiddleName: | J. | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 9257365757 | ||||||||
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| 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 | Y | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
No ID Information.