MEDICARE: SAN MATEO 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	:	1750553376
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SAN MATEO SURGERY CENTER LLC

Provider Business Mailing Address
First Line	:	66 BOVET RD
Second Line	:	SUITE 103
City	:	SAN MATEO
State	:	CA
Zip	:	94402-3125
Country	:	US
Telephone Number	:	650-570-0529
Fax Number	:

Provider Business Practice Location Address
First Line	:	66 BOVET RD
Second Line	:	SUITE 103
City	:	SAN MATEO
State	:	CA
Zip	:	94402-3125
Country	:	US
Telephone Number	:	650-570-0529
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MARK SONTAG
Credential	:	MD
Telephone Number	:	650-570-0529

Provider Enumeration Date	:	03/25/2008
Last Update Date	:	02/10/2015

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