Provider Demographics
NPI:1285622845
Name:PHYSICIANS' SURGERY CENTER OF FAYETTEVILLE, LLC
Entity type:Organization
Organization Name:PHYSICIANS' SURGERY CENTER OF FAYETTEVILLE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:RUSS
Authorized Official - Middle Name:
Authorized Official - Last Name:GREENE
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:479-527-0050
Mailing Address - Street 1:3733 N BUSINESS DR
Mailing Address - Street 2:SUITE #101
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72703-5203
Mailing Address - Country:US
Mailing Address - Phone:479-527-0050
Mailing Address - Fax:479-527-0030
Practice Address - Street 1:3733 N BUSINESS DR
Practice Address - Street 2:SUITE #101
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72703-5203
Practice Address - Country:US
Practice Address - Phone:479-527-0050
Practice Address - Fax:479-527-0030
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-07
Last Update Date:2009-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARAR4272261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR11062Medicare ID - Type UnspecifiedPROVIDER NUMBER