Basic Information
Provider Information | |||||||||
NPI: | 1972528537 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | SOUTH MAIN SURGERY CENTER INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 754 S MAIN ST | ||||||||
Address2: | SUITE 3 | ||||||||
City: | ST GEORGE | ||||||||
State: | UT | ||||||||
PostalCode: | 847705505 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4356282671 | ||||||||
FaxNumber: | 4356341601 | ||||||||
Practice Location | |||||||||
Address1: | 754 S MAIN ST | ||||||||
Address2: | SUITE 3 | ||||||||
City: | ST GEORGE | ||||||||
State: | UT | ||||||||
PostalCode: | 847705505 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4356282671 | ||||||||
FaxNumber: | 4356341601 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/13/2006 | ||||||||
LastUpdateDate: | 07/17/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | BURTON | ||||||||
AuthorizedOfficialFirstName: | STEVEN | ||||||||
AuthorizedOfficialMiddleName: | KENT | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 4356282671 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | DPM | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP1100X |   |   | N |   | Ambulatory Health Care Facilities | Clinic/Center | Podiatric | 261QA1903X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
ID Information
ID | Type | State | Issuer | Description | 870524073001 | 05 | UT |   | MEDICAID |