Provider Demographics
NPI:1194813840
Name:SURGERY CENTER OF WISCONSIN RAPIDS, LLC
Entity type:Organization
Organization Name:SURGERY CENTER OF WISCONSIN RAPIDS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:715-424-1881
Mailing Address - Street 1:PO BOX 8005
Mailing Address - Street 2:
Mailing Address - City:WISCONSIN RAPIDS
Mailing Address - State:WI
Mailing Address - Zip Code:54495-8005
Mailing Address - Country:US
Mailing Address - Phone:715-424-1881
Mailing Address - Fax:715-423-1602
Practice Address - Street 1:140 24TH ST S
Practice Address - Street 2:
Practice Address - City:WISCONSIN RAPIDS
Practice Address - State:WI
Practice Address - Zip Code:54494-1906
Practice Address - Country:US
Practice Address - Phone:715-424-1881
Practice Address - Fax:715-423-1602
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-10
Last Update Date:2023-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI41915300Medicaid
WI41915300Medicaid