MEDICARE: LAKE SPIVEY AMBULATORY SURGERY CARE, 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	031127	GA

General Provider Information

NPI Number	:	1487012480
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LAKE SPIVEY AMBULATORY SURGERY CARE, LLC

Provider Business Mailing Address
First Line	:	11 UPPER RIVERDALE RD SW
Second Line	:
City	:	RIVERDALE
State	:	GA
Zip	:	30274-2615
Country	:	US
Telephone Number	:	770-991-8000
Fax Number	:

Provider Business Practice Location Address
First Line	:	7813 SPIVEY STATION BLVD
Second Line	:	SUITE 100
City	:	JONESBORO
State	:	GA
Zip	:	30236-2900
Country	:	US
Telephone Number	:	770-268-6000
Fax Number	:

Authorized Official
Title or Position	:	CHIEF COMPLIANCE COUNSEL
Name	:	CHRISTOPHER DOAN
Credential	:
Telephone Number	:	909-235-4307

Provider Enumeration Date	:	02/04/2016
Last Update Date	:	02/04/2016

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