MEDICARE: OUTPATIENT SURGICAL CENTER OF PONCA CITY, 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	0021	OK

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	:	1659337194
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OUTPATIENT SURGICAL CENTER OF PONCA CITY, LLC

Provider Business Mailing Address
First Line	:	400 FAIRVIEW AVE
Second Line	:	SUITE 50
City	:	PONCA CITY
State	:	OK
Zip	:	74601-1920
Country	:	US
Telephone Number	:	580-762-0695
Fax Number	:	580-765-9406

Provider Business Practice Location Address
First Line	:	400 FAIRVIEW AVE
Second Line	:	SUITE 50
City	:	PONCA CITY
State	:	OK
Zip	:	74601-1920
Country	:	US
Telephone Number	:	580-762-0695
Fax Number	:	580-765-9406

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	MRS. STEFFI MOON COWAN
Credential	:
Telephone Number	:	580-762-0695

Provider Enumeration Date	:	04/25/2006
Last Update Date	:	11/01/2010

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