Provider Demographics
NPI:1316940539
Name:GRAND ISLAND SURGICAL CENTER LLC
Entity type:Organization
Organization Name:GRAND ISLAND SURGICAL CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:KEN
Authorized Official - Middle Name:
Authorized Official - Last Name:TERRY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:308-384-6400
Mailing Address - Street 1:PO BOX 5434
Mailing Address - Street 2:
Mailing Address - City:GRAND ISLAND
Mailing Address - State:NE
Mailing Address - Zip Code:68802-5434
Mailing Address - Country:US
Mailing Address - Phone:308-384-6400
Mailing Address - Fax:308-398-6420
Practice Address - Street 1:3610 RICHMOND CIR
Practice Address - Street 2:
Practice Address - City:GRAND ISLAND
Practice Address - State:NE
Practice Address - Zip Code:68803-3927
Practice Address - Country:US
Practice Address - Phone:308-384-6400
Practice Address - Fax:308-398-6420
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-05-23
Last Update Date:2011-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NEASC008261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE01383OtherBCBS PROVIDER ID
NE490004345OtherMEDICARE RR PROVIDER ID
NE490004345OtherMEDICARE RR PROVIDER ID
NE=========00Medicaid