Healthcare Provider Details

I. General information

NPI: 1942697735
Provider Name (Legal Business Name): SOUTH OMAHA SURGICAL CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/20/2015
Last Update Date: 10/09/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3201 S 24TH ST
OMAHA NE
68108-1825
US

IV. Provider business mailing address

21120 WASHINGTON PKWY
FRANKFORT IL
60423-3112
US

V. Phone/Fax

Practice location:
  • Phone: 402-504-4071
  • Fax: 402-504-4124
Mailing address:
  • Phone: 815-469-9750
  • Fax: 815-469-9752

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License NumberASC068
License Number StateNE

VIII. Authorized Official

Name: MR. DANIEL W BORVAN
Title or Position: VICE PRESIDENT
Credential: CRNA
Phone: 708-253-7258