Healthcare Provider Details

I. General information

NPI: 1801163811
Provider Name (Legal Business Name): ASHTABULA SURGERY CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/18/2011
Last Update Date: 11/18/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2893 N RIDGE E
ASHTABULA OH
44004-4134
US

IV. Provider business mailing address

2893 N RIDGE E
ASHTABULA OH
44004-4134
US

V. Phone/Fax

Practice location:
  • Phone: 440-998-0000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number0774AS
License Number StateOH

VIII. Authorized Official

Name: JODY BOHLKE
Title or Position: CREDENTIALING SPECIALIST
Credential:
Phone: 605-444-8279