Basic Information
| Provider Information | |||||||||
| NPI: | 1700815552 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SURGCENTER HUDSON, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2215 E WATERLOO RD | ||||||||
| Address2: | STE 313 | ||||||||
| City: | AKRON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 443123856 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3302082720 | ||||||||
| FaxNumber: | 3302082721 | ||||||||
| Practice Location | |||||||||
| Address1: | 5700 DARROW RD | ||||||||
| Address2: | STE 109 | ||||||||
| City: | HUDSON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 442365021 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3302082720 | ||||||||
| FaxNumber: | 3302082721 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/02/2006 | ||||||||
| LastUpdateDate: | 02/25/2019 | ||||||||
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| AuthorizedOfficialLastName: | LABABIDI | ||||||||
| AuthorizedOfficialFirstName: | WALID | ||||||||
| AuthorizedOfficialMiddleName: | G | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3302082720 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | CRNA | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA1903X | 0781AS | OH | Y | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
ID Information
| ID | Type | State | Issuer | Description | 2655201 | 05 | OH | MEDICAID |