MEDICARE: UNITED MEDICAL PARK ASC 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	:	1881238632
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	UNITED MEDICAL PARK ASC LLC

Provider Business Mailing Address
First Line	:	1 CHASE CORPORATE DR STE 200
Second Line	:
City	:	HOOVER
State	:	AL
Zip	:	35244-7060
Country	:	US
Telephone Number	:	205-824-6250
Fax Number	:

Provider Business Practice Location Address
First Line	:	1731 W RIDGEWAY AVE
Second Line	:
City	:	WATERLOO
State	:	IA
Zip	:	50701-4595
Country	:	US
Telephone Number	:	319-833-5858
Fax Number	:

Authorized Official
Title or Position	:	AUTHORIZED OFFICIAL
Name	:	LEE ANNE BLACKWELL
Credential	:
Telephone Number	:	205-824-6250

Provider Enumeration Date	:	11/05/2019
Last Update Date	:	11/05/2019

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