MEDICARE: MIDWAY SURGICAL SERVICES, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QA1903X	Ambulatory Surgical Clinic/Center

General Provider Information

NPI Number	:	1306357801
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MIDWAY SURGICAL SERVICES, LLC

Provider Business Mailing Address
First Line	:	6339 E SPEEDWAY BLVD
Second Line	:
City	:	TUCSON
State	:	AZ
Zip	:	85710-1147
Country	:	US
Telephone Number	:	520-323-8732
Fax Number	:

Provider Business Practice Location Address
First Line	:	4740 N CUMBERLAND AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60656-4239
Country	:	US
Telephone Number	:	520-323-8732
Fax Number	:

Authorized Official
Title or Position	:	LEAD PATIENT ADVOCATE
Name	:	AUTUMN ROMO
Credential	:
Telephone Number	:	520-258-0307

Provider Enumeration Date	:	10/24/2017
Last Update Date	:	10/24/2017

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