Basic Information
| Provider Information | |||||||||
| NPI: | 1932102498 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MERCY SURGERY CENTER, LP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2175 ROSALINE AVE | ||||||||
| Address2: | STE A | ||||||||
| City: | REDDING | ||||||||
| State: | CA | ||||||||
| PostalCode: | 960012509 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5302257400 | ||||||||
| FaxNumber: | 5302257405 | ||||||||
| Practice Location | |||||||||
| Address1: | 2175 ROSALINE AVE | ||||||||
| Address2: | STE A | ||||||||
| City: | REDDING | ||||||||
| State: | CA | ||||||||
| PostalCode: | 960012509 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5302257400 | ||||||||
| FaxNumber: | 5302257405 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/27/2005 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | BANISTER | ||||||||
| AuthorizedOfficialFirstName: | CYNTHIA | ||||||||
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| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 5302257400 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA1903X | CA | Y | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
ID Information
| ID | Type | State | Issuer | Description | SUR01643F | 05 | CA | MEDICAID |