MEDICARE: SPRING CREEK MEDICAL PARK OUTPATIENT 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	0110	CO

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1508863085
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SPRING CREEK MEDICAL PARK OUTPATIENT SURGERY CENTER LLC

Provider Business Mailing Address
First Line	:	2001 S SHIELDS ST
Second Line	:	BLDG F
City	:	FORT COLLINS
State	:	CO
Zip	:	80526-1827
Country	:	US
Telephone Number	:	970-232-1717
Fax Number	:	970-488-3950

Provider Business Practice Location Address
First Line	:	2001 S SHIELDS ST
Second Line	:	BLDG F
City	:	FORT COLLINS
State	:	CO
Zip	:	80526-1827
Country	:	US
Telephone Number	:	970-232-1717
Fax Number	:	970-488-3950

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	MR. JACK BURGIN
Credential	:
Telephone Number	:	970-232-1717

Provider Enumeration Date	:	06/30/2005
Last Update Date	:	02/22/2010

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