Basic Information
| Provider Information | |||||||||
| NPI: | 1831109875 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | M-S SURGERY CENTER LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3510 MARTIN LUTHER KING JR BLVD | ||||||||
| Address2: | |||||||||
| City: | LYNWOOD | ||||||||
| State: | CA | ||||||||
| PostalCode: | 902622010 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3106389391 | ||||||||
| FaxNumber: | 3106038749 | ||||||||
| Practice Location | |||||||||
| Address1: | 3510 MARTIN LUTHER KING JR BLVD | ||||||||
| Address2: | |||||||||
| City: | LYNWOOD | ||||||||
| State: | CA | ||||||||
| PostalCode: | 902622010 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3106389391 | ||||||||
| FaxNumber: | 3106038749 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/09/2006 | ||||||||
| LastUpdateDate: | 03/17/2009 | ||||||||
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| AuthorizedOfficialLastName: | SHAMMAS | ||||||||
| AuthorizedOfficialFirstName: | HANNA | ||||||||
| AuthorizedOfficialMiddleName: | JOHN | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 3106389391 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA1903X | S551041 | CA | Y | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
ID Information
| ID | Type | State | Issuer | Description | SUR51041G | 05 | CA | MEDICAID |