MEDICARE: SURGICENTER OF RACINE LTD

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	:	1518957851
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SURGICENTER OF RACINE LTD

Provider Business Mailing Address
First Line	:	5802 WASHINGTON AVE
Second Line	:	STE 204
City	:	RACINE
State	:	WI
Zip	:	53406-4050
Country	:	US
Telephone Number	:	261-886-9100
Fax Number	:	261-886-9130

Provider Business Practice Location Address
First Line	:	5802 WASHINGTON AVE
Second Line	:	STE 204
City	:	RACINE
State	:	WI
Zip	:	53406-4050
Country	:	US
Telephone Number	:	261-886-9100
Fax Number	:	261-886-9130

Authorized Official
Title or Position	:	DIRECTOR
Name	:	DENNIS J KONTRA
Credential	:	MD
Telephone Number	:	262-886-9100

Provider Enumeration Date	:	10/27/2005
Last Update Date	:	11/08/2016

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