MEDICARE: AMBULATORY SURGERY CENTER OF ROSEBURG, LLC

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	07 1542	OR

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	:	1174528038
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AMBULATORY SURGERY CENTER OF ROSEBURG, LLC

Provider Business Mailing Address
First Line	:	2801 NW MERCY DR
Second Line	:	STE 200
City	:	ROSEBURG
State	:	OR
Zip	:	97470-2348
Country	:	US
Telephone Number	:	541-677-2800
Fax Number	:	541-677-2820

Provider Business Practice Location Address
First Line	:	2801 NW MERCY DR
Second Line	:	STE 200
City	:	ROSEBURG
State	:	OR
Zip	:	97470-2348
Country	:	US
Telephone Number	:	541-677-2800
Fax Number	:	541-677-2820

Authorized Official
Title or Position	:	CHIEF OPERATING OFFICER
Name	:	DR. VANESSA T VU
Credential	:	M.D., PHD
Telephone Number	:	541-677-2800

Provider Enumeration Date	:	06/16/2005
Last Update Date	:	08/22/2020

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