Provider Demographics
NPI:1073694550
Name:ROCKWALL AMBULATORY SURGERY CENTER LLP
Entity Type:Organization
Organization Name:ROCKWALL AMBULATORY SURGERY CENTER LLP
Other - Org Name:BAYLOR SCOTT & WHITE SURGICARE - ROCKWALL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:JENETHA
Authorized Official - Middle Name:D
Authorized Official - Last Name:MORAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:972-763-3893
Mailing Address - Street 1:825 W YELLOWJACKET LANE
Mailing Address - Street 2:
Mailing Address - City:ROCKWALL
Mailing Address - State:TX
Mailing Address - Zip Code:75087-4818
Mailing Address - Country:US
Mailing Address - Phone:972-772-6166
Mailing Address - Fax:972-772-6167
Practice Address - Street 1:825 W YELLOWJACKET LANE
Practice Address - Street 2:
Practice Address - City:ROCKWALL
Practice Address - State:TX
Practice Address - Zip Code:75087-4818
Practice Address - Country:US
Practice Address - Phone:972-772-6166
Practice Address - Fax:972-772-6167
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-18
Last Update Date:2019-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX008418261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1900805Medicaid
TX1900805Medicaid