MEDICARE: COLLEGE PARK SURGERY CENTER

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	261Q00000X	Clinic/Center

General Provider Information

NPI Number	:	1104228758
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COLLEGE PARK SURGERY CENTER

Provider Business Mailing Address
First Line	:	PO BOX 3525
Second Line	:
City	:	VICTORIA
State	:	TX
Zip	:	77903-3525
Country	:	US
Telephone Number	:	361-652-0025
Fax Number	:

Provider Business Practice Location Address
First Line	:	3074 COLLEGE PARK DR
Second Line	:
City	:	CONROE
State	:	TX
Zip	:	77384-8002
Country	:	US
Telephone Number	:	361-652-0025
Fax Number	:

Authorized Official
Title or Position	:	GENERAL PARTNER
Name	:	PHRS SERVICES
Credential	:
Telephone Number	:	361-652-0025

Provider Enumeration Date	:	09/25/2014
Last Update Date	:	02/13/2015

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