Basic Information
| Provider Information | |||||||||
| NPI: | 1336202704 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SHERIDAN SURGICAL CENTER, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1524 W 5TH ST | ||||||||
| Address2: | |||||||||
| City: | SHERIDAN | ||||||||
| State: | WY | ||||||||
| PostalCode: | 828012707 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3076727874 | ||||||||
| FaxNumber: | 3076730655 | ||||||||
| Practice Location | |||||||||
| Address1: | 1524 W 5TH ST | ||||||||
| Address2: | |||||||||
| City: | SHERIDAN | ||||||||
| State: | WY | ||||||||
| PostalCode: | 828012707 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3076727874 | ||||||||
| FaxNumber: | 3076730655 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/18/2006 | ||||||||
| LastUpdateDate: | 03/27/2008 | ||||||||
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| AuthorizedOfficialLastName: | CARTER | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
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| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 3076727874 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | BSN | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA1903X | 07-012 | WY | Y | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
No ID Information.