MEDICARE: CORINTH 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	012	MS

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	3141695	OTHER	TN	BC/BS OF TN
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1891790887
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CORINTH SURGERY CENTER, LLC

Provider Business Mailing Address
First Line	:	13740 CYPRESS TERRACE CIR
Second Line	:	STE 501-503
City	:	FORT MYERS
State	:	FL
Zip	:	33907-8827
Country	:	US
Telephone Number	:	239-274-1000
Fax Number	:	239-274-1001

Provider Business Practice Location Address
First Line	:	401 ALCORN DR
Second Line	:	STE C
City	:	CORINTH
State	:	MS
Zip	:	38834-9067
Country	:	US
Telephone Number	:	662-293-2000
Fax Number	:	662-665-0857

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	MS. ANGELA JACKSON
Credential	:	R.N., B.S.N.
Telephone Number	:	662-293-2000

Provider Enumeration Date	:	06/16/2005
Last Update Date	:	08/22/2020

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