Basic Information
| Provider Information | |||||||||
| NPI: | 1255345229 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BEACON ORTHOPAEDICS SURGERY CENTER, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | SUMMIT SURGERY CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6480 HARRISON AVE STE 201 | ||||||||
| Address2: | |||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452477961 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5133547785 | ||||||||
| FaxNumber: | 5133547651 | ||||||||
| Practice Location | |||||||||
| Address1: | 501 E-BUSINESS WAY | ||||||||
| Address2: | |||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 45241 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5133543737 | ||||||||
| FaxNumber: | 5133543708 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/27/2006 | ||||||||
| LastUpdateDate: | 10/16/2019 | ||||||||
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| AuthorizedOfficialLastName: | BLANKEMEYER | ||||||||
| AuthorizedOfficialFirstName: | ANDREW | ||||||||
| AuthorizedOfficialMiddleName: | THOMAS | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 5135303062 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | BEACON ORTHOPAEDICS & SPORTS MEDICINE | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MHSA | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA1903X | 0711AS | OH | Y | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
ID Information
| ID | Type | State | Issuer | Description | 000000292071 | 01 | OH | ANTHEM | OTHER |