=====================================================
General NPI Number Information
=====================================================
NPI Number | 1144216847
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | RIVER PARK ASC LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/27/2005
-----------------------------------------------------
Last Update Date | 02/16/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 107 FRONT ST STE.1100
-----------------------------------------------------
City | VIDALIA
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 71373-2836
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 318-336-2218
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 107 FRONT ST STE.1100
-----------------------------------------------------
City | VIDALIA
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 71373-2836
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 318-336-2218
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | MARCI MCGRAW
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 318-336-2225
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QA1903X
-----------------------------------------------------
Taxonomy Name | Ambulatory Surgical Clinic/Center
-----------------------------------------------------
License Number | 128
-----------------------------------------------------
License Number State | LA
-----------------------------------------------------