Provider Demographics
NPI:1093746380
Name:SURGICENTER GROUP LLC
Entity Type:Organization
Organization Name:SURGICENTER GROUP LLC
Other - Org Name:FORT WAYNE AMBULATORY SURGERY CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PART OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:S
Authorized Official - Last Name:RAPKIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:765-286-8888
Mailing Address - Street 1:PO BOX 457
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:IN
Mailing Address - Zip Code:47375-0457
Mailing Address - Country:US
Mailing Address - Phone:765-966-1945
Mailing Address - Fax:765-966-2975
Practice Address - Street 1:321 E WAYNE ST
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46802-2713
Practice Address - Country:US
Practice Address - Phone:260-422-5976
Practice Address - Fax:260-969-1041
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-05
Last Update Date:2009-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000532877OtherANTHEM PIN
IN200875480AMedicaid
OH2883910Medicaid
IN200875480AMedicaid
OH2883910Medicaid