Basic Information
| Provider Information | |||||||||
| NPI: | 1780998633 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PARKRIDGE SURGERY CENTER LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | PARKRIDGE SURGERY CENTER LLC CRNA | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 190 PARKRIDGE DR STE 108 | ||||||||
| Address2: | |||||||||
| City: | COLUMBIA | ||||||||
| State: | SC | ||||||||
| PostalCode: | 292121748 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8032962548 | ||||||||
| FaxNumber: | 8032962548 | ||||||||
| Practice Location | |||||||||
| Address1: | 190 PARKRIDGE DR STE 108 | ||||||||
| Address2: | |||||||||
| City: | COLUMBIA | ||||||||
| State: | SC | ||||||||
| PostalCode: | 292121748 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8032962548 | ||||||||
| FaxNumber: | 8032962548 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/03/2010 | ||||||||
| LastUpdateDate: | 08/03/2010 | ||||||||
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| AuthorizedOfficialLastName: | KEENE | ||||||||
| AuthorizedOfficialFirstName: | EMILIE | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 8034074950 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | PARKRIDGE SURGERY CENTER LLC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA1903X | ASF-078 | SC | Y | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
No ID Information.