Healthcare Provider Details

I. General information

NPI: 1538280284
Provider Name (Legal Business Name): PHYSICIANS SURGERY CENTER OF MODESTO LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/02/2007
Last Update Date: 11/19/2025
Certification Date: 11/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

609 E ORANGEBURG AVE # B
MODESTO CA
95350-5580
US

IV. Provider business mailing address

609 E ORANGEBURG AVE BLDG B
MODESTO CA
95350-5512
US

V. Phone/Fax

Practice location:
  • Phone: 209-527-6700
  • Fax:
Mailing address:
  • Phone: 209-527-6700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number0557938
License Number StateCA

VIII. Authorized Official

Name: ERIC BOON
Title or Position: MARKET PRESIDENT
Credential:
Phone: 480-567-0269