=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790231256
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GOLDEN GATE SURGERY CENTER LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/25/2016
-----------------------------------------------------
Last Update Date | 02/23/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 450 SUTTER ST 5TH FL
-----------------------------------------------------
City | SAN FRANCISCO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94108-4206
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 415-409-1367
-----------------------------------------------------
Fax | 415-896-4922
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 490 POST ST STE 900
-----------------------------------------------------
City | SAN FRANCISCO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94102-1401
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 415-409-1367
-----------------------------------------------------
Fax | 415-896-4922
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEDICAL DIRECTOR
-----------------------------------------------------
Name | DR. NICHOLAS COLYVAS
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 415-409-1367
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QA1903X
-----------------------------------------------------
Taxonomy Name | Ambulatory Surgical Clinic/Center
-----------------------------------------------------
License Number | A050788
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------