=====================================================
General NPI Number Information
=====================================================
NPI Number | 1386721249
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ALLIED PHYSICIANS SURGERY CENTER, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/31/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 53990 CARMICHAEL DR SUITE 100
-----------------------------------------------------
City | SOUTH BEND
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46635-1582
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 574-243-9700
-----------------------------------------------------
Fax | 574-247-3300
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 53990 CARMICHAEL DR SUITE 100
-----------------------------------------------------
City | SOUTH BEND
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46635-1582
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 574-243-9700
-----------------------------------------------------
Fax | 574-247-3300
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CFO
-----------------------------------------------------
Name | MS. THOMASINE HARRISON
-----------------------------------------------------
Credential | CPA
-----------------------------------------------------
Telephone | 574-247-3322
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QA1903X
-----------------------------------------------------
Taxonomy Name | Ambulatory Surgical Clinic/Center
-----------------------------------------------------
License Number | 06-010984-1
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------