Basic Information
| Provider Information | |||||||||
| NPI: | 1578574463 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MEDICAL CONSULTANTS SURGERY CENTER LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2218 | ||||||||
| Address2: | |||||||||
| City: | MUNCIE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 473070218 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7652812188 | ||||||||
| FaxNumber: | 7652812062 | ||||||||
| Practice Location | |||||||||
| Address1: | 800 S TILLOTSON AVE | ||||||||
| Address2: | |||||||||
| City: | MUNCIE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 473044529 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7652812000 | ||||||||
| FaxNumber: | 7652812062 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/10/2006 | ||||||||
| LastUpdateDate: | 01/06/2015 | ||||||||
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| AuthorizedOfficialLastName: | BIDWELL | ||||||||
| AuthorizedOfficialFirstName: | SHERRI | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | BUSINESS OFFICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 7652812188 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA1903X | Y | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
ID Information
| ID | Type | State | Issuer | Description | P00369153 | 01 | IN | MERICARE B RAILROAD | OTHER | 200432090A | 05 | IN | MEDICAID |