Provider Demographics
NPI:1043236664
Name:ST. MARY'S AMBULATORY SURGERY CENTER, LLC
Entity Type:Organization
Organization Name:ST. MARY'S AMBULATORY SURGERY CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICER/AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:DANIELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:NUGENT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:804-287-7878
Mailing Address - Street 1:1501 MAPLE AVE
Mailing Address - Street 2:STE 300
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23226-2553
Mailing Address - Country:US
Mailing Address - Phone:804-287-7878
Mailing Address - Fax:804-287-7879
Practice Address - Street 1:1501 MAPLE AVE
Practice Address - Street 2:STE 300
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23226-2553
Practice Address - Country:US
Practice Address - Phone:804-287-7878
Practice Address - Fax:804-287-7879
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-15
Last Update Date:2020-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VAOH 702261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1043236664Medicaid
VAP00380790OtherRAILROAD MEDICARE
VA1043236664Medicaid