Healthcare Provider Details

I. General information

NPI: 1609376409
Provider Name (Legal Business Name): KOKOMO AMBULATORY SURGERY CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/19/2018
Last Update Date: 02/19/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

107 S WASHINGTON ST STE A
KOKOMO IN
46901-4601
US

IV. Provider business mailing address

PO BOX 5748
LAFAYETTE IN
47903-5748
US

V. Phone/Fax

Practice location:
  • Phone: 765-450-6735
  • Fax: 765-838-3200
Mailing address:
  • Phone: 765-714-4344
  • 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: SHAZIA M SIDDIQUI
Title or Position: OWNER
Credential: MD
Phone: 765-450-6735