Healthcare Provider Details

I. General information

NPI: 1033195912
Provider Name (Legal Business Name): SURGICAL ASSOCIATES ENDOSCOPY CLINIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/21/2005
Last Update Date: 04/14/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

310 S PENNSYLVANIA ST SUITE 201
ABERDEEN SD
57401-4553
US

IV. Provider business mailing address

310 S PENNSYLVANIA ST SUITE 201
ABERDEEN SD
57401-4553
US

V. Phone/Fax

Practice location:
  • Phone: 605-229-1367
  • Fax: 605-229-1002
Mailing address:
  • Phone: 605-229-1367
  • Fax: 605-229-1002

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number48090
License Number StateSD

VIII. Authorized Official

Name: MR. BRADLEY W OLSON
Title or Position: GENERAL MANAGER
Credential:
Phone: 605-229-1367