Healthcare Provider Details

I. General information

NPI: 1588254791
Provider Name (Legal Business Name): LAFAYETTE SURGERY CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/21/2021
Last Update Date: 04/11/2023
Certification Date: 04/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3738 LANDMARK DR STE C
LAFAYETTE IN
47905-6655
US

IV. Provider business mailing address

PO BOX 772723
DETROIT MI
48277-2723
US

V. Phone/Fax

Practice location:
  • Phone: 765-807-2780
  • Fax: 317-706-3417
Mailing address:
  • Phone: 765-807-2780
  • Fax: 317-706-3417

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: EDWARD KOWLOWITZ
Title or Position: OWNER
Credential: MD
Phone: 317-706-7246