MEDICARE: EXECUTIVE PARK 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

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

General Provider Information

NPI Number	:	1699736777
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EXECUTIVE PARK SURGERY CENTER, LLC

Provider Business Mailing Address
First Line	:	3314 S 70TH ST
Second Line	:
City	:	FORT SMITH
State	:	AR
Zip	:	72903-5052
Country	:	US
Telephone Number	:	479-424-2744
Fax Number	:	479-424-2745

Provider Business Practice Location Address
First Line	:	3314 S 70TH ST
Second Line	:
City	:	FORT SMITH
State	:	AR
Zip	:	72903-5052
Country	:	US
Telephone Number	:	479-424-2744
Fax Number	:	479-424-2745

Authorized Official
Title or Position	:	PRESIDENT
Name	:	RANDY M ENNEN
Credential	:	M.D.
Telephone Number	:	479-424-2744

Provider Enumeration Date	:	03/29/2006
Last Update Date	:	12/16/2010

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