MEDICARE: CONCHO SURGICAL PARTNERSHIP, LTD

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	008290	TX

General Provider Information

NPI Number	:	1801825955
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CONCHO SURGICAL PARTNERSHIP, LTD

Provider Business Mailing Address
First Line	:	4482 SUNSET DR
Second Line	:
City	:	SAN ANGELO
State	:	TX
Zip	:	76901-5611
Country	:	US
Telephone Number	:	325-486-5800
Fax Number	:	325-486-5850

Provider Business Practice Location Address
First Line	:	4482 SUNSET DR
Second Line	:
City	:	SAN ANGELO
State	:	TX
Zip	:	76901-5611
Country	:	US
Telephone Number	:	325-486-5800
Fax Number	:	325-486-5850

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	MR. CHUCK DAWSON
Credential	:
Telephone Number	:	325-486-5801

Provider Enumeration Date	:	07/01/2006
Last Update Date	:	11/21/2007

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