Basic Information
| Provider Information | |||||||||
| NPI: | 1760518617 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MEDICAL GROUP SURGERY CENTER LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | HEALTHPARTNERS MEDICAL GROUP SUGERY CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1225 E COOLSPRING AVE | ||||||||
| Address2: | |||||||||
| City: | MICHIGAN CITY | ||||||||
| State: | IN | ||||||||
| PostalCode: | 463606312 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2198796531 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1225 E COOLSPRING AVE | ||||||||
| Address2: | |||||||||
| City: | MICHIGAN CITY | ||||||||
| State: | IN | ||||||||
| PostalCode: | 463606312 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2198796531 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/26/2007 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| AuthorizedOfficialLastName: | THORDARSON | ||||||||
| AuthorizedOfficialFirstName: | G | ||||||||
| AuthorizedOfficialMiddleName: | THOR | ||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 2198796531 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA1903X | IN | Y | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
No ID Information.