Healthcare Provider Details

I. General information

NPI: 1649534843
Provider Name (Legal Business Name): SURGERY CENTER OF WASILLA, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/02/2012
Last Update Date: 05/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3190 E MERIDIAN PARK LOOP STE 111
WASILLA AK
99654-7422
US

IV. Provider business mailing address

3190 E MERIDIAN PARK LOOP STE 111
WASILLA AK
99654-7422
US

V. Phone/Fax

Practice location:
  • Phone: 907-631-3578
  • Fax: 907-782-4561
Mailing address:
  • Phone: 907-631-3578
  • Fax: 907-782-4561

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number976033
License Number StateAK

VII. Legacy identifiers

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

VIII. Authorized Official

Name: JOHN THOMAS GRISSOM
Title or Position: PRESIDENT
Credential: MD
Phone: 907-631-3578