MEDICARE: SURGERY CENTER OF CROCKETT, 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

General Provider Information

NPI Number	:	1205146404
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SURGERY CENTER OF CROCKETT, LLC

Provider Business Mailing Address
First Line	:	200 RENAISSANCE WAY
Second Line	:
City	:	CROCKETT
State	:	TX
Zip	:	75835-1814
Country	:	US
Telephone Number	:	936-307-9191
Fax Number	:	936-544-7401

Provider Business Practice Location Address
First Line	:	200 RENAISSANCE WAY
Second Line	:
City	:	CROCKETT
State	:	TX
Zip	:	75835-1814
Country	:	US
Telephone Number	:	936-307-9191
Fax Number	:	936-544-7401

Authorized Official
Title or Position	:	MEDICAL DIRECTOR
Name	:	JOHN PATRICK WALKER
Credential	:	M.D.
Telephone Number	:	936-307-9191

Provider Enumeration Date	:	10/21/2010
Last Update Date	:	10/21/2010

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