Basic Information
Provider Information | |||||||||
NPI: | 1356718514 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | WACO AMBULATORY SURGERY CENTER, LP | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | WACO CARDIOLOGY CATH LAB & SURGERY CENTER | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | DEPT# 6014, PO BOX 4417 | ||||||||
Address2: |   | ||||||||
City: | HOUSTON | ||||||||
State: | TX | ||||||||
PostalCode: | 772104417 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6106448900 | ||||||||
FaxNumber: | 4849240053 | ||||||||
Practice Location | |||||||||
Address1: | 7125 SANGER RD | ||||||||
Address2: | SUITE E | ||||||||
City: | WACO | ||||||||
State: | TX | ||||||||
PostalCode: | 767124053 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2547760800 | ||||||||
FaxNumber: | 2547760801 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/24/2015 | ||||||||
LastUpdateDate: | 08/11/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | MILLER | ||||||||
AuthorizedOfficialFirstName: | GREGG | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | SENIOR VICE PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 6106448900 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | MD | ||||||||
NPICertificationDate: | 08/11/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA1903X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
No ID Information.