MEDICARE: SWEETWATER SURGERY CENTER 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	05-124	WY

General Provider Information

NPI Number	:	1336144617
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SWEETWATER SURGERY CENTER LLC

Provider Business Mailing Address
First Line	:	2761 COMMERCIAL WAY
Second Line	:
City	:	ROCK SPRINGS
State	:	WY
Zip	:	82901-4753
Country	:	US
Telephone Number	:	307-382-6873
Fax Number	:	307-382-6869

Provider Business Practice Location Address
First Line	:	2761 COMMERCIAL WAY
Second Line	:
City	:	ROCK SPRINGS
State	:	WY
Zip	:	82901-4753
Country	:	US
Telephone Number	:	307-382-6873
Fax Number	:	307-382-6869

Authorized Official
Title or Position	:	MEDICAL DIRECTOR
Name	:	PETER JENSEN
Credential	:	MD
Telephone Number	:	307-382-6873

Provider Enumeration Date	:	06/14/2005
Last Update Date	:	11/02/2007

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