MEDICARE: SAGAMORE SURGICAL SERVICES, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QA1903X	Ambulatory Surgical Clinic/Center	05-006126-1	IN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1003816307
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SAGAMORE SURGICAL SERVICES, INC.

Provider Business Mailing Address
First Line	:	PO BOX 112
Second Line	:
City	:	MUNCIE
State	:	IN
Zip	:	47308-0112
Country	:	US
Telephone Number	:	765-284-0493
Fax Number	:	765-284-2434

Provider Business Practice Location Address
First Line	:	2320 CONCORD RD
Second Line	:	STE B
City	:	LAFAYETTE
State	:	IN
Zip	:	47909-2708
Country	:	US
Telephone Number	:	765-474-7854
Fax Number	:

Authorized Official
Title or Position	:	ADMINISTRATOR DON
Name	:	SHELBY ATKINSON BROUILLETTE
Credential	:	RN
Telephone Number	:	765-474-7838

Provider Enumeration Date	:	07/28/2005
Last Update Date	:	04/22/2025

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