Provider Demographics
NPI:1194718593
Name:LEONARD DZUBOW AMBULATORY SURGICAL CENTER LLC
Entity type:Organization
Organization Name:LEONARD DZUBOW AMBULATORY SURGICAL CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LEONARD
Authorized Official - Middle Name:MARK
Authorized Official - Last Name:DZUBOW
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:484-621-0082
Mailing Address - Street 1:101 CHESLEY DR
Mailing Address - Street 2:
Mailing Address - City:MEDIA
Mailing Address - State:PA
Mailing Address - Zip Code:19063-1761
Mailing Address - Country:US
Mailing Address - Phone:484-621-0082
Mailing Address - Fax:484-621-0083
Practice Address - Street 1:101 CHESLEY DR
Practice Address - Street 2:
Practice Address - City:MEDIA
Practice Address - State:PA
Practice Address - Zip Code:19063-1761
Practice Address - Country:US
Practice Address - Phone:484-621-0082
Practice Address - Fax:484-621-0083
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-31
Last Update Date:2014-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA16731501261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA075847Medicare PIN