MEDICARE: STATESBORO AMBULATORY SURGERY CENTER INC

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	:	1700152113
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	STATESBORO AMBULATORY SURGERY CENTER INC

Provider Business Mailing Address
First Line	:	95 BEL AIR DR
Second Line	:
City	:	STATESBORO
State	:	GA
Zip	:	30461-6879
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	95 BEL AIR DR
Second Line	:
City	:	STATESBORO
State	:	GA
Zip	:	30461-6879
Country	:	US
Telephone Number	:	912-489-6519
Fax Number	:	912-764-7882

Authorized Official
Title or Position	:	PRESIDENT/OWNER
Name	:	ROBERT W. CUSHNER
Credential	:	DPM
Telephone Number	:	912-489-6519

Provider Enumeration Date	:	03/29/2012
Last Update Date	:	04/03/2012

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