Basic Information
| Provider Information | |||||||||
| NPI: | 1700057254 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | NORTH STATE SURGERY CENTERS, LP | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | MERCY SURGERY CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2175 ROSALINE AVE | ||||||||
| Address2: | STE A | ||||||||
| City: | REDDING | ||||||||
| State: | CA | ||||||||
| PostalCode: | 960012549 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5302257400 | ||||||||
| FaxNumber: | 5302257405 | ||||||||
| Practice Location | |||||||||
| Address1: | 2175 ROSALINE AVE | ||||||||
| Address2: | STE A | ||||||||
| City: | REDDING | ||||||||
| State: | CA | ||||||||
| PostalCode: | 960012549 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5302257400 | ||||||||
| FaxNumber: | 5302257405 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/12/2008 | ||||||||
| LastUpdateDate: | 06/28/2013 | ||||||||
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| AuthorizedOfficialLastName: | REED | ||||||||
| AuthorizedOfficialFirstName: | KATHERINE | ||||||||
| AuthorizedOfficialMiddleName: | L. | ||||||||
| AuthorizedOfficialTitleorPosition: | OFFICER, AUTHORIZED OFFICIAL, MEDIC | ||||||||
| AuthorizedOfficialTelephone: | 9727633859 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA1903X | 230000354 | CA | Y | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
ID Information
| ID | Type | State | Issuer | Description | SUR01643F | 05 | CA | MEDICAID | P00094713 | 01 | CA | RAILROAD MEDICARE | OTHER |