Healthcare Provider Details

I. General information

NPI: 1477470847
Provider Name (Legal Business Name): UPPER MISSISSIPPI SURGERY CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/06/2026
Last Update Date: 07/06/2026
Certification Date: 07/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

454 BADGER RD
HAZEL GREEN WI
53811-9787
US

IV. Provider business mailing address

454 BADGER RD
HAZEL GREEN WI
53811-9787
US

V. Phone/Fax

Practice location:
  • Phone: 608-608-2576
  • Fax: 605-274-6186
Mailing address:
  • Phone: 608-608-2576
  • Fax: 605-274-6186

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number
License Number State

VIII. Authorized Official

Name: SUSAN MARIE GOURLEY
Title or Position: ADMINISTRATOR
Credential:
Phone: 608-473-1700