=====================================================
General NPI Number Information
=====================================================
NPI Number | 1770632259
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FAR HILLS SURGICAL CENTER, LTD
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/10/2007
-----------------------------------------------------
Last Update Date | 10/08/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6601 CENTERVILLE BUSINESS PARKWAY SUITE 301
-----------------------------------------------------
City | CENTERVILLE
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45459
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 937-294-9840
-----------------------------------------------------
Fax | 937-294-9843
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6601 CENTERVILLE BUSINESS PARKWAY SUITE 301
-----------------------------------------------------
City | CENTERVILLE
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45459
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 937-294-9840
-----------------------------------------------------
Fax | 937-294-9843
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | MICHAEL GALVIN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 937-294-9840
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QA1903X
-----------------------------------------------------
Taxonomy Name | Ambulatory Surgical Clinic/Center
-----------------------------------------------------
License Number | 0716AS
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------