MEDICARE: BSMH AMBULATORY VENTURES II 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

General Provider Information

NPI Number	:	1578146429
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BSMH AMBULATORY VENTURES II LLC

Provider Business Mailing Address
First Line	:	4147 WESTFORD PL
Second Line	:
City	:	CANFIELD
State	:	OH
Zip	:	44406-8086
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4147 WESTFORD DR
Second Line	:
City	:	CANFIELD
State	:	OH
Zip	:	44406-8086
Country	:	US
Telephone Number	:	330-702-1489
Fax Number	:

Authorized Official
Title or Position	:	VP REIMBURSEMENT
Name	:	KIMBERLY M RALSTON
Credential	:
Telephone Number	:	419-695-0397

Provider Enumeration Date	:	04/29/2021
Last Update Date	:	10/26/2023

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