Basic Information
| Provider Information | |||||||||
| NPI: | 1407338338 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SELIM SURGERY CENTER, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 215 W PRIEN LAKE RD | ||||||||
| Address2: | |||||||||
| City: | LAKE CHARLES | ||||||||
| State: | LA | ||||||||
| PostalCode: | 706018450 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3375028706 | ||||||||
| FaxNumber: | 3372101271 | ||||||||
| Practice Location | |||||||||
| Address1: | 215 W PRIEN LAKE RD | ||||||||
| Address2: | SUITE B | ||||||||
| City: | LAKE CHARLES | ||||||||
| State: | LA | ||||||||
| PostalCode: | 70601 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3375028706 | ||||||||
| FaxNumber: | 3372101271 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/06/2018 | ||||||||
| LastUpdateDate: | 03/03/2020 | ||||||||
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| AuthorizedOfficialLastName: | SELIM | ||||||||
| AuthorizedOfficialFirstName: | NIAZY | ||||||||
| AuthorizedOfficialMiddleName: | MAHMOUD | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT/CEO | ||||||||
| AuthorizedOfficialTelephone: | 3375028706 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD, PHD, FACS | ||||||||
| NPICertificationDate: | 03/03/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA1903X | MD207592 | LA | Y | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
ID Information
| ID | Type | State | Issuer | Description | 2388533 | 05 | LA | MEDICAID |