Basic Information
| Provider Information | |||||||||
| NPI: | 1427307578 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | HEMLOCK AMBULATORY SURGERY CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 101 PRESTON CT STE 104 | ||||||||
| Address2: | |||||||||
| City: | MACON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 312105771 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4787452385 | ||||||||
| FaxNumber: | 4787451225 | ||||||||
| Practice Location | |||||||||
| Address1: | 101 PRESTON CT STE 104 | ||||||||
| Address2: | |||||||||
| City: | MACON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 312105771 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4787452385 | ||||||||
| FaxNumber: | 4787451225 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/05/2012 | ||||||||
| LastUpdateDate: | 07/22/2013 | ||||||||
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| AuthorizedOfficialLastName: | TAFOR | ||||||||
| AuthorizedOfficialFirstName: | STEPHEN | ||||||||
| AuthorizedOfficialMiddleName: | N | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 4787452385 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA1903X | 011-473 | GA | Y | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
ID Information
| ID | Type | State | Issuer | Description | 003132720A | 05 | GA | MEDICAID |