Provider Demographics
NPI:1801825880
Name:SURGERY CENTER AT RIVER ROAD, LLC
Entity type:Organization
Organization Name:SURGERY CENTER AT RIVER ROAD, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SHAREHOLDER
Authorized Official - Prefix:
Authorized Official - First Name:GWENDOLYN
Authorized Official - Middle Name:S
Authorized Official - Last Name:MAXWELL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:520-382-1084
Mailing Address - Street 1:2490 E. RIVER ROAD
Mailing Address - Street 2:SUITE 150
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85718-6522
Mailing Address - Country:US
Mailing Address - Phone:520-382-1084
Mailing Address - Fax:520-615-4572
Practice Address - Street 1:2490 E. RIVER ROAD
Practice Address - Street 2:SUITE 150
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85718-6522
Practice Address - Country:US
Practice Address - Phone:520-382-1084
Practice Address - Fax:520-615-4572
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-01
Last Update Date:2014-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ0110903261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical