Healthcare Provider Details

I. General information

NPI: 1881238632
Provider Name (Legal Business Name): UNITED MEDICAL PARK ASC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/05/2019
Last Update Date: 11/05/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1731 W RIDGEWAY AVE
WATERLOO IA
50701-4595
US

IV. Provider business mailing address

1 CHASE CORPORATE DR STE 200
HOOVER AL
35244-7060
US

V. Phone/Fax

Practice location:
  • Phone: 319-833-5858
  • Fax:
Mailing address:
  • Phone: 205-824-6250
  • Fax:

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: LEE ANNE BLACKWELL
Title or Position: AUTHORIZED OFFICIAL
Credential:
Phone: 205-824-6250