Healthcare Provider Details

I. General information

NPI: 1477108900
Provider Name (Legal Business Name): CLEARWAY SURGERY CENTER OF CRESTVIEW, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/01/2019
Last Update Date: 05/17/2022
Certification Date: 05/17/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

180A E REDSTONE AVE
CRESTVIEW FL
32539-5348
US

IV. Provider business mailing address

201 DEFENSE HWY STE 205
ANNAPOLIS MD
21401-7096
US

V. Phone/Fax

Practice location:
  • Phone: 850-484-4080
  • Fax: 850-484-8801
Mailing address:
  • Phone: 855-527-7246
  • Fax: 833-810-1165

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: KACEY A MONTGOMERY
Title or Position: REGIONAL MEDICAL DIRECTOR
Credential: M.D.
Phone: 850-791-6895