MEDICARE: SURGERY CENTER OF CINCINNATI, 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	0587AS	OH

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
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	375674700	OTHER	KY	KENTUCKY WORKERS COMP
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
5	000000156597	OTHER	OH	ANTHEM PROVIDER ID
6	61101	OTHER	OH	HUMANA PROVIDER ID

General Provider Information

NPI Number	:	1538122957
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SURGERY CENTER OF CINCINNATI, LLC

Provider Business Mailing Address
First Line	:	4415 AICHOLTZ RD
Second Line	:
City	:	CINCINNATI
State	:	OH
Zip	:	45245-1506
Country	:	US
Telephone Number	:	513-947-1130
Fax Number	:	513-947-8541

Provider Business Practice Location Address
First Line	:	4415 AICHOLTZ RD
Second Line	:
City	:	CINCINNATI
State	:	OH
Zip	:	45245-1506
Country	:	US
Telephone Number	:	513-947-1130
Fax Number	:	513-947-8541

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	VIRGIL RAY CANTRELL
Credential	:
Telephone Number	:	513-947-1130

Provider Enumeration Date	:	04/07/2006
Last Update Date	:	04/12/2011

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Directions to “SURGERY CENTER OF CINCINNATI, LLC ” Practice Location

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