Provider Demographics
NPI:1528077658
Name:PRINCE WILLIAM AMBULATORY SURGERY CENTER, LLC
Entity type:Organization
Organization Name:PRINCE WILLIAM AMBULATORY SURGERY CENTER, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICER / AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:KRISTEN
Authorized Official - Middle Name:
Authorized Official - Last Name:O'CONNOR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-376-7315
Mailing Address - Street 1:8644 SUDLEY RD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:MANASSAS
Mailing Address - State:VA
Mailing Address - Zip Code:20110-4417
Mailing Address - Country:US
Mailing Address - Phone:703-369-8525
Mailing Address - Fax:571-229-1533
Practice Address - Street 1:8644 SUDLEY RD
Practice Address - Street 2:SUITE 201
Practice Address - City:MANASSAS
Practice Address - State:VA
Practice Address - Zip Code:20110-4417
Practice Address - Country:US
Practice Address - Phone:703-369-8525
Practice Address - Fax:571-229-1533
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-07
Last Update Date:2024-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VAOH695261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
2579620OtherUHC
9731258OtherCIGNA
2142411OtherMDIPA/OPTIMUM CHOICE
VA010274656Medicaid
186080OtherANTHEM HEALTHKEEPERS
VA186080OtherANTHEM
2142411OtherMAMSI/UHC
2142411OtherMAMSI/UHC
VA010274656Medicaid
2142411OtherMDIPA/OPTIMUM CHOICE
9731258OtherCIGNA
=========OtherTRICARE NORTH
=========OtherALLIANCE