MEDICARE: PHYSICIANS 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	2006-ASF-74408	UT

General Provider Information

NPI Number	:	1356395586
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PHYSICIANS SURGERY CENTER, LLC

Provider Business Mailing Address
First Line	:	1485 E 3900 S
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84124-1412
Country	:	US
Telephone Number	:	801-277-2062
Fax Number	:	801-274-3233

Provider Business Practice Location Address
First Line	:	1485 E 3900 S
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84124-1412
Country	:	US
Telephone Number	:	801-277-2062
Fax Number	:	801-274-3233

Authorized Official
Title or Position	:	M.D. MANAGER - MEMBER
Name	:	KEVIN H. CHARLTON
Credential	:	M.D.
Telephone Number	:	801-277-2062

Provider Enumeration Date	:	05/20/2006
Last Update Date	:	07/08/2014

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