Provider Demographics
NPI:1073946216
Name:MADISON PHYSICIAN SURGERY CENTER, LLC
Entity Type:Organization
Organization Name:MADISON PHYSICIAN SURGERY CENTER, LLC
Other - Org Name:MADISON PHYSICIANS SURGERY CENTER, LLC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:MEREDITH
Authorized Official - Middle Name:GORE
Authorized Official - Last Name:WARF
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-605-5393
Mailing Address - Street 1:4510 LAKELAND DR
Mailing Address - Street 2:
Mailing Address - City:FLOWOOD
Mailing Address - State:MS
Mailing Address - Zip Code:39232-9583
Mailing Address - Country:US
Mailing Address - Phone:601-605-5393
Mailing Address - Fax:601-605-6393
Practice Address - Street 1:4510 LAKELAND DR
Practice Address - Street 2:
Practice Address - City:FLOWOOD
Practice Address - State:MS
Practice Address - Zip Code:39232-9583
Practice Address - Country:US
Practice Address - Phone:601-944-1717
Practice Address - Fax:601-944-9780
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-08-12
Last Update Date:2019-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS04024064Medicaid