Healthcare Provider Details

I. General information

NPI: 1629045133
Provider Name (Legal Business Name): MONTICELLO COMMUNITY SURGERY CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/02/2006
Last Update Date: 06/02/2023
Certification Date: 06/02/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2331 SEMINOLE LANE SUITE 201
CHARLOTTESVILLE VA
22901-8319
US

IV. Provider business mailing address

2331 SEMINOLE LANE SUITE 201
CHARLOTTESVILLE VA
22901-8319
US

V. Phone/Fax

Practice location:
  • Phone: 434-293-4995
  • Fax: 434-971-3434
Mailing address:
  • Phone: 434-293-4995
  • Fax: 434-971-3434

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License NumberOH 662
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JESSIE WAGNER
Title or Position: ADMINISTRATOR
Credential:
Phone: 434-971-3406