=====================================================
General NPI Number Information
=====================================================
NPI Number | 1558517821
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BABCOCK SURGICAL CENTER, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/18/2008
-----------------------------------------------------
Last Update Date | 02/16/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2425 BABCOCK RD SUITE #106
-----------------------------------------------------
City | SAN ANTONIO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78229-4895
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 210-255-8084
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | MSC 150 P.O. BOX 2458
-----------------------------------------------------
City | SAN ANTONIO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78229-2458
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 210-255-8084
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | MR. ALEKSEI GUTENBERG
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 210-255-8084
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QA1903X
-----------------------------------------------------
Taxonomy Name | Ambulatory Surgical Clinic/Center
-----------------------------------------------------
License Number | 008675
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------