Healthcare Provider Details

I. General information

NPI: 1609257310
Provider Name (Legal Business Name): RIVERSIDE SURGERY CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/18/2015
Last Update Date: 07/13/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3556 RIVERSIDE DR
MACON GA
31210-2509
US

IV. Provider business mailing address

3556 RIVERSIDE DR
MACON GA
31210-2509
US

V. Phone/Fax

Practice location:
  • Phone: 478-475-9204
  • Fax: 478-475-9572
Mailing address:
  • Phone: 678-426-2188
  • Fax: 770-874-8950

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: MS. JANA SUE TAYLOR
Title or Position: CREDENTIALING SPECIALIST
Credential:
Phone: 678-426-2188