=====================================================
General NPI Number Information
=====================================================
NPI Number | 1144259870
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BLACKHAWK SURGERY CENTER, A MEDICAL CORP.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/03/2006
-----------------------------------------------------
Last Update Date | 10/31/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3601 BLACKHAWK PLAZA CIRCLE
-----------------------------------------------------
City | DANVILLE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94506
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 925-736-5757
-----------------------------------------------------
Fax | 925-736-5763
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11999 SAN VICENTE BL. # 440
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90049
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-440-3131
-----------------------------------------------------
Fax | 310-472-9582
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. STEPHEN J. RONAN
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 925-736-5757
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QA1903X
-----------------------------------------------------
Taxonomy Name | Ambulatory Surgical Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------