MEDICARE: MADISON AMBULATORY SURGERY CENTER, 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	PENDING	MS

General Provider Information

NPI Number	:	1659313930
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MADISON AMBULATORY SURGERY CENTER, LLC

Provider Business Mailing Address
First Line	:	1883 HIGHWAY 43 S
Second Line	:	SUITE J
City	:	CANTON
State	:	MS
Zip	:	39046-8405
Country	:	US
Telephone Number	:	601-942-7254
Fax Number	:

Provider Business Practice Location Address
First Line	:	1883 HIGHWAY 43 S
Second Line	:	SUITE J
City	:	CANTON
State	:	MS
Zip	:	39046-8405
Country	:	US
Telephone Number	:	601-942-7254
Fax Number	:

Authorized Official
Title or Position	:	DIRECTOR
Name	:	ANDREA MARTELL
Credential	:
Telephone Number	:	360-402-1433

Provider Enumeration Date	:	06/12/2006
Last Update Date	:	07/21/2022

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