Healthcare Provider Details

I. General information

NPI: 1538164546
Provider Name (Legal Business Name): SURGERY CENTER AT PELHAM, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/16/2005
Last Update Date: 12/19/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2755 S HIGHWAY 14
GREER SC
29650-4926
US

IV. Provider business mailing address

13740 CYPRESS TERRACE CIR STE 501-503
FORT MYERS FL
33907-8827
US

V. Phone/Fax

Practice location:
  • Phone: 864-560-5555
  • Fax: 864-560-5542
Mailing address:
  • Phone: 239-274-1000
  • Fax: 239-274-1001

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License NumberASF-091
License Number StateSC

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: MR. BILL HAZEN
Title or Position: ADMINISTRATOR
Credential:
Phone: 864-560-5555