MEDICARE: PONCE DE LEON 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	:	1740738095
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PONCE DE LEON SURGERY CENTER, LLC

Provider Business Mailing Address
First Line	:	552 PONCE DE LEON AVE NE
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30308-1806
Country	:	US
Telephone Number	:	404-343-2672
Fax Number	:

Provider Business Practice Location Address
First Line	:	552 PONCE DE LEON AVE NE
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30308-1806
Country	:	US
Telephone Number	:	404-343-2672
Fax Number	:

Authorized Official
Title or Position	:	PRACTICE ADMINISTRATOR
Name	:	EBONY PATTERSON-SETTLES
Credential	:
Telephone Number	:	404-343-2672

Provider Enumeration Date	:	09/15/2016
Last Update Date	:	02/03/2017

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