=====================================================
General NPI Number Information
=====================================================
NPI Number | 1376228361
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SPRINGFIELD REGIONAL OUTPATIENT SURGERY CENTER LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/19/2023
-----------------------------------------------------
Last Update Date | 06/19/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2610 N LIMESTONE ST
-----------------------------------------------------
City | SPRINGFIELD
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45503-1114
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 937-390-8310
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2610 N LIMESTONE ST
-----------------------------------------------------
City | SPRINGFIELD
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45503-1114
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 937-390-8310
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | VP REIMBURSEMENT
-----------------------------------------------------
Name | KIMBERLY RALSTON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 419-996-5119
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QA1903X
-----------------------------------------------------
Taxonomy Name | Ambulatory Surgical Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------