Provider Demographics
NPI:1093705774
Name:SURGICENTER OF MANSFIELD, LTD.
Entity Type:Organization
Organization Name:SURGICENTER OF MANSFIELD, LTD.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:LINDA
Authorized Official - Middle Name:S
Authorized Official - Last Name:EFAW
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:419-774-9410
Mailing Address - Street 1:1030 CRICKET LN
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:44906-4104
Mailing Address - Country:US
Mailing Address - Phone:419-774-9410
Mailing Address - Fax:419-774-1072
Practice Address - Street 1:1030 CRICKET LN
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:OH
Practice Address - Zip Code:44906-4104
Practice Address - Country:US
Practice Address - Phone:419-774-9410
Practice Address - Fax:419-774-1072
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-25
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH0469AS261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2090697Medicaid
OH=========-00OtherBWC