MEDICARE: BRECKENRIDGE 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		TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	ASC239	OTHER	TX	PTAN
2	HHO67A	OTHER	TX	BLUECROSS BLUE SHEILD

General Provider Information

NPI Number	:	1962568725
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BRECKENRIDGE SURGERY CENTER LP

Provider Business Mailing Address
First Line	:	3201 E PRESIDENT GEORGE BUSH HWY
Second Line	:	SUITE 100
City	:	RICHARDSON
State	:	TX
Zip	:	75082-3566
Country	:	US
Telephone Number	:	972-470-5000
Fax Number	:	972-470-5861

Provider Business Practice Location Address
First Line	:	3201 E PRESIDENT GEORGE BUSH HWY
Second Line	:	SUITE 100
City	:	RICHARDSON
State	:	TX
Zip	:	75082-3566
Country	:	US
Telephone Number	:	972-470-5859
Fax Number	:	972-470-5861

Authorized Official
Title or Position	:	OR DIRECTOR
Name	:	MISS MAMIE SUE CLARK
Credential	:
Telephone Number	:	972-470-5859

Provider Enumeration Date	:	12/28/2006
Last Update Date	:	07/21/2022

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