Provider Demographics
NPI:1033195912
Name:SURGICAL ASSOCIATES ENDOSCOPY CLINIC LLC
Entity Type:Organization
Organization Name:SURGICAL ASSOCIATES ENDOSCOPY CLINIC LLC
Other - Org Name:AVERA ENDOSCOPY/SURGICAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:GENERAL MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:BRADLEY
Authorized Official - Middle Name:W
Authorized Official - Last Name:OLSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:605-229-1367
Mailing Address - Street 1:310 S PENNSYLVANIA ST
Mailing Address - Street 2:SUITE 201
Mailing Address - City:ABERDEEN
Mailing Address - State:SD
Mailing Address - Zip Code:57401-4553
Mailing Address - Country:US
Mailing Address - Phone:605-229-1367
Mailing Address - Fax:605-229-1002
Practice Address - Street 1:310 S PENNSYLVANIA ST
Practice Address - Street 2:SUITE 201
Practice Address - City:ABERDEEN
Practice Address - State:SD
Practice Address - Zip Code:57401-4553
Practice Address - Country:US
Practice Address - Phone:605-229-1367
Practice Address - Fax:605-229-1002
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-21
Last Update Date:2009-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD48090261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD5490320Medicaid
SD5490320Medicaid