Provider Demographics
NPI:1033173711
Name:MARYSVILLE OHIO SURGICAL CENTER
Entity Type:Organization
Organization Name:MARYSVILLE OHIO SURGICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:JO ELLEN
Authorized Official - Middle Name:
Authorized Official - Last Name:BRADEN
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:937-642-6622
Mailing Address - Street 1:122 PROFFESSIONAL PKWY
Mailing Address - Street 2:
Mailing Address - City:MARYSVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43040-8053
Mailing Address - Country:US
Mailing Address - Phone:937-642-6622
Mailing Address - Fax:937-642-6635
Practice Address - Street 1:122 PROFFESSIONAL PKWY
Practice Address - Street 2:
Practice Address - City:MARYSVILLE
Practice Address - State:OH
Practice Address - Zip Code:43040-8053
Practice Address - Country:US
Practice Address - Phone:937-642-6622
Practice Address - Fax:937-642-6635
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-12
Last Update Date:2008-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH0751AS261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2538409Medicaid
OH3611931Medicare UPIN