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General NPI Number Information
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NPI Number | 1003816307
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Entity Type | Organization
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Legal Business Name | SAGAMORE SURGICAL SERVICES, INC.
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Dates
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Enumeration Date | 07/28/2005
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Last Update Date | 04/22/2025
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Provider Practice Location Address
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Address Line | 2320 CONCORD RD STE B
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City | LAFAYETTE
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State | IN
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Zip | 47909-2708
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Country | US
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Telephone | 765-474-7854
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 112
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City | MUNCIE
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State | IN
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Zip | 47308-0112
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Country | US
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Telephone | 765-284-0493
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Fax | 765-284-2434
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Authorized Official
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Title or Position | ADMINISTRATOR DON
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Name | SHELBY ATKINSON BROUILLETTE
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Credential | RN
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Telephone | 765-474-7838
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QA1903X
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Taxonomy Name | Ambulatory Surgical Clinic/Center
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License Number | 05-006126-1
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License Number State | IN
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