Healthcare Provider Details

I. General information

NPI: 1174636237
Provider Name (Legal Business Name): SOUTHEAST SURGERY CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/15/2006
Last Update Date: 02/11/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5255 E STOP 11 RD # 110
INDIANAPOLIS IN
46237-6340
US

IV. Provider business mailing address

5255 E STOP 11 RD # 110
INDIANAPOLIS IN
46237-6340
US

V. Phone/Fax

Practice location:
  • Phone: 317-884-5200
  • Fax: 317-884-5360
Mailing address:
  • Phone: 317-884-5200
  • Fax: 317-884-5360

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: JANE KELLER
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 317-802-2000