=====================================================
General NPI Number Information
=====================================================
NPI Number | 1962583369
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FAMILY SURGERY CENTER, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/18/2006
-----------------------------------------------------
Last Update Date | 06/12/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1801 19TH AVE SW
-----------------------------------------------------
City | WILLMAR
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 56201-4946
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 320-235-7700
-----------------------------------------------------
Fax | 320-235-7701
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1801 19TH AVE SW
-----------------------------------------------------
City | WILLMAR
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 56201-4946
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 320-235-7700
-----------------------------------------------------
Fax | 320-235-7701
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | MRS. CARMEN MACIK
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 320-214-5759
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207L00000X
-----------------------------------------------------
Taxonomy Name | Anesthesiology Physician
-----------------------------------------------------
License Number | 330845
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------