Healthcare Provider Details

I. General information

NPI: 1073009304
Provider Name (Legal Business Name): SUSITNA SURGERY CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/10/2018
Last Update Date: 08/21/2024
Certification Date: 08/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2490 S WOODWORTH LOOP STE 100
PALMER AK
99645-7410
US

IV. Provider business mailing address

2490 S WOODWORTH LOOP STE 100
PALMER AK
99645-7410
US

V. Phone/Fax

Practice location:
  • Phone: 907-861-6540
  • Fax: 907-861-6309
Mailing address:
  • Phone: 907-861-5640
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: KRISTY MUSIC
Title or Position: AO-DIRECTOR, PROVIDER ENROLLMENT
Credential:
Phone: 615-465-7377