MEDICARE: PREMIER RURAL DB & GANTT 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

General Provider Information

NPI Number	:	1588408033
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PREMIER RURAL DB & GANTT SURGERY CENTER, LLC

Provider Business Mailing Address
First Line	:	403 W. OAK STREET
Second Line	:	SUITE 101
City	:	EL DORADO
State	:	AR
Zip	:	71730-4573
Country	:	US
Telephone Number	:	870-875-1481
Fax Number	:	870-875-1486

Provider Business Practice Location Address
First Line	:	403 W. OAK STREET
Second Line	:	SUITE 101
City	:	EL DORADO
State	:	AR
Zip	:	71730-4573
Country	:	US
Telephone Number	:	870-875-1481
Fax Number	:	870-875-1486

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	MR. MIAN IMRAN AHMED
Credential	:
Telephone Number	:	870-875-1481

Provider Enumeration Date	:	06/20/2024
Last Update Date	:	06/20/2024

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