MEDICARE: SURGERY CENTER AT RIVER ROAD, 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	0110903	AZ

General Provider Information

NPI Number	:	1801825880
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SURGERY CENTER AT RIVER ROAD, LLC

Provider Business Mailing Address
First Line	:	2490 E. RIVER ROAD
Second Line	:	SUITE 150
City	:	TUCSON
State	:	AZ
Zip	:	85718-6522
Country	:	US
Telephone Number	:	520-382-1084
Fax Number	:	520-615-4572

Provider Business Practice Location Address
First Line	:	2490 E. RIVER ROAD
Second Line	:	SUITE 150
City	:	TUCSON
State	:	AZ
Zip	:	85718-6522
Country	:	US
Telephone Number	:	520-382-1084
Fax Number	:	520-615-4572

Authorized Official
Title or Position	:	SHAREHOLDER
Name	:	GWENDOLYN S MAXWELL
Credential	:	M.D.
Telephone Number	:	520-382-1084

Provider Enumeration Date	:	07/01/2006
Last Update Date	:	09/22/2014

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