MEDICARE: PINE GROVE AMBULATORY SURGICAL

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	:	1689860124
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PINE GROVE AMBULATORY SURGICAL

Provider Business Mailing Address
First Line	:	10 TIMBERVIEW LANE
Second Line	:
City	:	RUSSELL
State	:	PA
Zip	:	16345
Country	:	US
Telephone Number	:	814-757-5819
Fax Number	:	814-757-5829

Provider Business Practice Location Address
First Line	:	10 TIMBERVIEW LANE
Second Line	:
City	:	RUSSELL
State	:	PA
Zip	:	16345
Country	:	US
Telephone Number	:	814-757-5819
Fax Number	:	814-757-5829

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	MRS. EMILEE S LANGER
Credential	:	MPH
Telephone Number	:	814-688-0426

Provider Enumeration Date	:	09/19/2007
Last Update Date	:	02/19/2008

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