Provider Demographics
NPI:1538167176
Name:SOUTHWEST OHIO AMBULATORY SURGERY CENTER, LTD
Entity type:Organization
Organization Name:SOUTHWEST OHIO AMBULATORY SURGERY CENTER, LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:JEFF
Authorized Official - Middle Name:W
Authorized Official - Last Name:NICOLAI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:513-425-7327
Mailing Address - Street 1:295 N BREIEL BLVD
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:OH
Mailing Address - Zip Code:45042-3807
Mailing Address - Country:US
Mailing Address - Phone:513-425-7327
Mailing Address - Fax:513-425-0960
Practice Address - Street 1:295 N BREIEL BLVD
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:OH
Practice Address - Zip Code:45042-3807
Practice Address - Country:US
Practice Address - Phone:513-425-0930
Practice Address - Fax:513-425-0960
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-08
Last Update Date:2011-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH338261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200451270AMedicaid
KY36001352Medicaid
OH2046057Medicaid
OH=========00OtherBUREAU OF WORKERS COMP
OH3610981Medicare ID - Type UnspecifiedPROVIDER NUMBER