Healthcare Provider Details

I. General information

NPI: 1093214819
Provider Name (Legal Business Name): PREMIER SURGICAL CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/07/2018
Last Update Date: 03/12/2024
Certification Date: 03/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

160 FOUNTAINS BLVD
MADISON MS
39110
US

IV. Provider business mailing address

160 FOUNTAINS BLVD STE C
MADISON MS
39110-6380
US

V. Phone/Fax

Practice location:
  • Phone: 601-968-8132
  • Fax: 601-944-9780
Mailing address:
  • Phone: 601-391-2525
  • Fax: 601-586-5315

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: REBEKAH ELIZABETH HENDERSON
Title or Position: OR AMINISTRATOR
Credential: RN
Phone: 601-391-2525