Basic Information
| Provider Information | |||||||||
| NPI: | 1467415950 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | OUTPATIENT SURGERY CENTER OF LAKEWOOD LP | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | LAKEWOOD SURGICAL CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2201 WADSWORTH BLVD | ||||||||
| Address2: | |||||||||
| City: | LAKEWOOD | ||||||||
| State: | CO | ||||||||
| PostalCode: | 802145708 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3032340445 | ||||||||
| FaxNumber: | 3032327182 | ||||||||
| Practice Location | |||||||||
| Address1: | 2201 WADSWORTH BLVD | ||||||||
| Address2: | |||||||||
| City: | LAKEWOOD | ||||||||
| State: | CO | ||||||||
| PostalCode: | 802145708 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3032340445 | ||||||||
| FaxNumber: | 3032327182 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/07/2006 | ||||||||
| LastUpdateDate: | 10/13/2008 | ||||||||
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| AuthorizedOfficialLastName: | LIEDTKE | ||||||||
| AuthorizedOfficialFirstName: | DON | ||||||||
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| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 6153445507 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA1903X | 0672 | CO | Y | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
ID Information
| ID | Type | State | Issuer | Description | 04510038 | 05 | CO | MEDICAID |