Basic Information
| Provider Information | |||||||||
| NPI: | 1376148593 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | UNITED SURGEONS, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4455 EDISON LAKES PKWY | ||||||||
| Address2: | |||||||||
| City: | MISHAWAKA | ||||||||
| State: | IN | ||||||||
| PostalCode: | 465451414 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5742316800 | ||||||||
| FaxNumber: | 5742316845 | ||||||||
| Practice Location | |||||||||
| Address1: | 4455 EDISON LAKES PKWY | ||||||||
| Address2: | |||||||||
| City: | MISHAWAKA | ||||||||
| State: | IN | ||||||||
| PostalCode: | 465451414 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5742316800 | ||||||||
| FaxNumber: | 5742316845 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/04/2020 | ||||||||
| LastUpdateDate: | 12/10/2020 | ||||||||
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| AuthorizedOfficialLastName: | MACKEN-MARBLE | ||||||||
| AuthorizedOfficialFirstName: | KELLY | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 5742316800 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 12/10/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 207L00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |
No ID Information.