MEDICARE: FREMONT AMBULATORY SURGERY CENTER, LP

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	140000600	CA
2	261QA1903X	Ambulatory Surgical Clinic/Center	140000527	CA

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	:	1851369284
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FREMONT AMBULATORY SURGERY CENTER, LP

Provider Business Mailing Address
First Line	:	39350 CIVIC CENTER DR STE 280
Second Line	:
City	:	FREMONT
State	:	CA
Zip	:	94538-2331
Country	:	US
Telephone Number	:	510-456-4600
Fax Number	:	510-456-4601

Provider Business Practice Location Address
First Line	:	39350 CIVIC CENTER DR SUITE 100
Second Line	:
City	:	FREMONT
State	:	CA
Zip	:	94538-2331
Country	:	US
Telephone Number	:	510-456-4600
Fax Number	:	510-794-6822

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	MR. JOHN MAZOROS
Credential	:
Telephone Number	:	510-456-4650

Provider Enumeration Date	:	03/10/2006
Last Update Date	:	11/02/2017

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