Basic Information
| Provider Information | |||||||||
| NPI: | 1245288257 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SURGICAL CENTER OF GREENSBORO, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 705 GREEN VALLEY RD | ||||||||
| Address2: | |||||||||
| City: | GREENSBORO | ||||||||
| State: | NC | ||||||||
| PostalCode: | 274087019 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3362720012 | ||||||||
| FaxNumber: | 3362724063 | ||||||||
| Practice Location | |||||||||
| Address1: | 705 GREEN VALLEY RD | ||||||||
| Address2: | |||||||||
| City: | GREENSBORO | ||||||||
| State: | NC | ||||||||
| PostalCode: | 274087019 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3362720012 | ||||||||
| FaxNumber: | 3362724063 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/04/2006 | ||||||||
| LastUpdateDate: | 01/24/2019 | ||||||||
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| AuthorizedOfficialLastName: | GRAHAM | ||||||||
| AuthorizedOfficialFirstName: | JENNIFER | ||||||||
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| AuthorizedOfficialTitleorPosition: | CHIEF ADMINISTRATIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 3362720012 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNameSuffix: | JR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA1903X | AS0018 | NC | Y | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
ID Information
| ID | Type | State | Issuer | Description | 3409924 | 05 | NC | MEDICAID |