Provider Demographics
NPI:1962513788
Name:SURGERY CENTER OF DECATUR LP
Entity type:Organization
Organization Name:SURGERY CENTER OF DECATUR LP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:LATHRAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:256-560-2890
Mailing Address - Street 1:PO BOX 1164
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:AL
Mailing Address - Zip Code:35602-1164
Mailing Address - Country:US
Mailing Address - Phone:256-560-2890
Mailing Address - Fax:256-560-2891
Practice Address - Street 1:1122 14TH AVENUE SE
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:AL
Practice Address - Zip Code:35601-3361
Practice Address - Country:US
Practice Address - Phone:256-560-2890
Practice Address - Fax:256-560-2891
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2013-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL12143261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ALABC0073CMedicaid
ALABC0073CMedicaid