Healthcare Provider Details

I. General information

NPI: 1356395586
Provider Name (Legal Business Name): PHYSICIANS SURGERY CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/20/2006
Last Update Date: 07/08/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1485 E 3900 S
SALT LAKE CITY UT
84124-1412
US

IV. Provider business mailing address

1485 E 3900 S
SALT LAKE CITY UT
84124-1412
US

V. Phone/Fax

Practice location:
  • Phone: 801-277-2062
  • Fax: 801-274-3233
Mailing address:
  • Phone: 801-277-2062
  • Fax: 801-274-3233

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number2006-ASF-74408
License Number StateUT

VIII. Authorized Official

Name: KEVIN H. CHARLTON
Title or Position: M.D. MANAGER - MEMBER
Credential: M.D.
Phone: 801-277-2062