Provider Demographics
NPI:1700606340
Name:GRANT AMBULATORY SURGERY CENTER
Entity type:Organization
Organization Name:GRANT AMBULATORY SURGERY CENTER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:GRANT
Authorized Official - Last Name:GILLUM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:765-651-4278
Mailing Address - Street 1:801 W GARDNER DR
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:IN
Mailing Address - Zip Code:46952-1819
Mailing Address - Country:US
Mailing Address - Phone:765-651-4278
Mailing Address - Fax:765-664-6445
Practice Address - Street 1:803 W GARDNER DR
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:IN
Practice Address - Zip Code:46952-1819
Practice Address - Country:US
Practice Address - Phone:765-651-4278
Practice Address - Fax:765-664-6445
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-10-16
Last Update Date:2024-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical