MEDICARE: DOCTORS SURGERY CENTER OF KINGMAN, 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	OSC 2913	AZ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	AZ0207340	OTHER	AZ	BCBSAZ
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1407819857
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DOCTORS SURGERY CENTER OF KINGMAN, LLC

Provider Business Mailing Address
First Line	:	1740 SYCAMORE AVENUE
Second Line	:
City	:	KINGMAN
State	:	AZ
Zip	:	86409
Country	:	US
Telephone Number	:	928-681-4214
Fax Number	:	928-681-4226

Provider Business Practice Location Address
First Line	:	1740 SYCAMORE AVE
Second Line	:
City	:	KINGMAN
State	:	AZ
Zip	:	86409-0927
Country	:	US
Telephone Number	:	928-681-4214
Fax Number	:	928-681-4226

Authorized Official
Title or Position	:	EXECUTIVE ADMINISTRATOR
Name	:	MR. MYRON E MACHULA
Credential	:
Telephone Number	:	928-681-4214

Provider Enumeration Date	:	04/07/2006
Last Update Date	:	08/22/2020

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