Healthcare Provider Details

I. General information

NPI: 1073828315
Provider Name (Legal Business Name): GOVERNOR'S PLACE AMBULATORY SURGERY CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/11/2010
Last Update Date: 08/11/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3025 GOVERNORS PLACE BLVD
DAYTON OH
45409-1330
US

IV. Provider business mailing address

3025 GOVERNORS PLACE BLVD
DAYTON OH
45409-1330
US

V. Phone/Fax

Practice location:
  • Phone: 937-293-5567
  • Fax: 937-293-5568
Mailing address:
  • Phone: 937-293-5567
  • Fax: 937-293-5568

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number1936460
License Number StateOH

VIII. Authorized Official

Name: DR. HEIDI B DONNELLY
Title or Position: OWNER/PRESIDENT CEO
Credential: MD
Phone: 937-293-5567