MEDICARE: WEST ALLIS 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

General Provider Information

NPI Number	:	1699383703
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WEST ALLIS SURGERY CENTER LLC

Provider Business Mailing Address
First Line	:	10150 W NATIONAL AVE STE 350
Second Line	:
City	:	WEST ALLIS
State	:	WI
Zip	:	53227-2153
Country	:	US
Telephone Number	:	414-877-6412
Fax Number	:

Provider Business Practice Location Address
First Line	:	10150 W NATIONAL AVE STE 350
Second Line	:
City	:	WEST ALLIS
State	:	WI
Zip	:	53227-2153
Country	:	US
Telephone Number	:	414-296-0039
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	TINA ROBERTS
Credential	:
Telephone Number	:	414-296-0039

Provider Enumeration Date	:	07/15/2020
Last Update Date	:	01/26/2021

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