Basic Information
| Provider Information | |||||||||
| NPI: | 1205859550 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | COMMUNITY SURGERY & LASER CENTER, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2 FARM COLONY DRIVE | ||||||||
| Address2: | |||||||||
| City: | WARREN | ||||||||
| State: | PA | ||||||||
| PostalCode: | 163655206 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8147262303 | ||||||||
| FaxNumber: | 8147267459 | ||||||||
| Practice Location | |||||||||
| Address1: | 2 FARM COLONY DRIVE | ||||||||
| Address2: | |||||||||
| City: | WARREN | ||||||||
| State: | PA | ||||||||
| PostalCode: | 163655206 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8147262303 | ||||||||
| FaxNumber: | 8147267459 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/26/2006 | ||||||||
| LastUpdateDate: | 10/21/2020 | ||||||||
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| AuthorizedOfficialLastName: | WUEBBOLT | ||||||||
| AuthorizedOfficialFirstName: | GORDON | ||||||||
| AuthorizedOfficialMiddleName: | EDGAR | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER/MD | ||||||||
| AuthorizedOfficialTelephone: | 7164846700 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 10/21/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA1903X | MD052930L | PA | N | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical | 261QA1903X | 20821501 | PA | Y | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
ID Information
| ID | Type | State | Issuer | Description | 154-823-4255 | 01 | PA | NPI-DR. GORDON WUEBBOLT | OTHER |