Basic Information
| Provider Information | |||||||||
| NPI: | 1760627830 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MUSCULOSKELETAL AMBULATORY SURGERY CENTER, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | THE SURGERY CENTER AT POINTE WEST - EAST CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6015 POINTE WEST BLVD | ||||||||
| Address2: | |||||||||
| City: | BRADENTON | ||||||||
| State: | FL | ||||||||
| PostalCode: | 342095532 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9417820101 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1917 WORTH CT | ||||||||
| Address2: | |||||||||
| City: | BRADENTON | ||||||||
| State: | FL | ||||||||
| PostalCode: | 342112110 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9417820101 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/03/2008 | ||||||||
| LastUpdateDate: | 07/21/2010 | ||||||||
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| AuthorizedOfficialLastName: | DUCK | ||||||||
| AuthorizedOfficialFirstName: | PAUL | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 9417921404 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | MUSCULOSKELETAL AMBULATORY SURGERY CENTER | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA1903X | 1314 | FL | Y | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
ID Information
| ID | Type | State | Issuer | Description | 075448000 | 05 | FL | MEDICAID | 6AA | 01 | FL | BCBS OF FL | OTHER |