=====================================================
General NPI Number Information
=====================================================
NPI Number | 1649748708
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ANKENY MEDICAL PARK SURGERY CENTER LC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/07/2018
-----------------------------------------------------
Last Update Date | 12/26/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3625 N ANKENY BLVD STE J
-----------------------------------------------------
City | ANKENY
-----------------------------------------------------
State | IA
-----------------------------------------------------
Zip | 50023-4610
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 515-965-2200
-----------------------------------------------------
Fax | 515-446-2767
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3625 N ANKENY BLVD STE J
-----------------------------------------------------
City | ANKENY
-----------------------------------------------------
State | IA
-----------------------------------------------------
Zip | 50023-4610
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 515-965-2213
-----------------------------------------------------
Fax | 515-446-2767
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | BOARD OF MANAGERS MEMBER
-----------------------------------------------------
Name | MR. THOMAS P MULROONEY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 515-241-4027
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QA1903X
-----------------------------------------------------
Taxonomy Name | Ambulatory Surgical Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------