=====================================================
General NPI Number Information
=====================================================
NPI Number | 1821166521
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PHYSICIANS SURGERY CENTER LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/01/2006
-----------------------------------------------------
Last Update Date | 07/21/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1800 HIGHWAY 95
-----------------------------------------------------
City | BULLHEAD CITY
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 86442-6803
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 928-763-8443
-----------------------------------------------------
Fax | 928-763-3073
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1800 HIGHWAY 95
-----------------------------------------------------
City | BULLHEAD CITY
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 86442-6803
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 928-763-8443
-----------------------------------------------------
Fax | 928-763-3073
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | VICE PRESIDENT
-----------------------------------------------------
Name | MS. SUSAN N. GLESMANN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 928-763-8443
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QA1903X
-----------------------------------------------------
Taxonomy Name | Ambulatory Surgical Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------