Healthcare Provider Details

I. General information

NPI: 1912240003
Provider Name (Legal Business Name): ELO OUTPATIENT SURGERY CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/27/2013
Last Update Date: 03/27/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4050 RIVERSIDE DR
MACON GA
31210-1805
US

IV. Provider business mailing address

840 PINE STREET 900
MACON GA
31201-5100
US

V. Phone/Fax

Practice location:
  • Phone: 478-746-2888
  • Fax: 478-746-2889
Mailing address:
  • Phone: 478-746-2888
  • Fax: 478-746-2889

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number63974
License Number StateGA

VIII. Authorized Official

Name: DR. NNAEMEKA M UMERAH
Title or Position: MEDICAL DIRECTOR
Credential: MD
Phone: 478-746-2888