=====================================================
General NPI Number Information
=====================================================
NPI Number | 1174709786
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ROCKSIDE ROAD SURGERY CENTER, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/14/2008
-----------------------------------------------------
Last Update Date | 01/14/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6701 ROCKSIDE RD SUITE 101
-----------------------------------------------------
City | INDEPENDENCE
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44131-2358
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 216-524-0120
-----------------------------------------------------
Fax | 216-524-0455
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6701 ROCKSIDE RD SUITE 101
-----------------------------------------------------
City | INDEPENDENCE
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44131-2358
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 216-524-0120
-----------------------------------------------------
Fax | 216-524-0455
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OPERATIONS MANAGER
-----------------------------------------------------
Name | MR. MARK JANACK
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 216-447-6070
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QA1903X
-----------------------------------------------------
Taxonomy Name | Ambulatory Surgical Clinic/Center
-----------------------------------------------------
License Number | 0722AS
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------