=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114929957
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | OPHTHALMIC OUTPATIENT SURGERY CENTER PARTNERS, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/11/2005
-----------------------------------------------------
Last Update Date | 02/26/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 550 CONNELLS PARK LN
-----------------------------------------------------
City | BATON ROUGE
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70806-6539
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 225-923-8250
-----------------------------------------------------
Fax | 225-925-0225
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 550 CONNELL PARK LN SUITE B
-----------------------------------------------------
City | BATON ROUGE
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70806-6539
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 225-925-2031
-----------------------------------------------------
Fax | 225-924-2809
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CFO
-----------------------------------------------------
Name | MR. CHARLES H WILLIAMSON JR.
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 225-925-2031
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QA1903X
-----------------------------------------------------
Taxonomy Name | Ambulatory Surgical Clinic/Center
-----------------------------------------------------
License Number | 129
-----------------------------------------------------
License Number State | LA
-----------------------------------------------------