Healthcare Provider Details

I. General information

NPI: 1124022595
Provider Name (Legal Business Name): THE OUTPATIENT SURGERY CENTER OF CEDAR RAPIDS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/13/2005
Last Update Date: 01/02/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1075 1ST AVENUE SE
CEDAR RAPIDS IA
52402
US

IV. Provider business mailing address

1075 1ST AVENUE SE
CEDAR RAPIDS IA
52402
US

V. Phone/Fax

Practice location:
  • Phone: 319-558-4800
  • Fax: 319-558-4806
Mailing address:
  • Phone: 319-558-4802
  • Fax: 319-558-4806

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VII. Legacy identifiers

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

# 1
Identifier0610238
Identifier TypeMEDICAID
Identifier StateIA
Identifier Issuer
# 2
Identifier61016
Identifier TypeOTHER
Identifier StateIA
Identifier IssuerWELLMARK-BC/BS ID NUMBER

VIII. Authorized Official

Name: KALLEMEYN SCOTT
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 319-558-4801