Basic Information
| Provider Information | |||||||||
| NPI: | 1902844426 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SOUTH ARLINGTON SURGICAL PROVIDERS, LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | SAME DAY SURGICARE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 350 E INTERSTATE 20 STE 200 | ||||||||
| Address2: | |||||||||
| City: | ARLINGTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 760181119 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8177846771 | ||||||||
| FaxNumber: | 8177846743 | ||||||||
| Practice Location | |||||||||
| Address1: | 350 E INTERSTATE 20 STE 200 | ||||||||
| Address2: | |||||||||
| City: | ARLINGTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 760181119 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8177846771 | ||||||||
| FaxNumber: | 8177846743 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/04/2006 | ||||||||
| LastUpdateDate: | 12/30/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | O'NEAL | ||||||||
| AuthorizedOfficialFirstName: | STEPHANIE | ||||||||
| AuthorizedOfficialMiddleName: | L. | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF ADMINISTRATIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 8177846771 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 12/30/2019 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA1903X | 000391 | TX | N | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical | 261QA1903X | 130217 | TX | Y | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
ID Information
| ID | Type | State | Issuer | Description | 087953817 | 05 | TX | MEDICAID | 087953801 | 05 | TX | MEDICAID |