Provider Demographics
NPI:1114374469
Name:SOUTH
Entity Type:Organization
Organization Name:SOUTH
Other - Org Name:FAIRMONT ASC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:COREY
Authorized Official - Middle Name:T
Authorized Official - Last Name:WELCHLIN
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:507-238-4949
Mailing Address - Street 1:717 S STATE ST
Mailing Address - Street 2:STE 900
Mailing Address - City:FAIRMONT
Mailing Address - State:MN
Mailing Address - Zip Code:56031-4469
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:717 S STATE ST
Practice Address - Street 2:STE 1000
Practice Address - City:FAIRMONT
Practice Address - State:MN
Practice Address - Zip Code:56031-4469
Practice Address - Country:US
Practice Address - Phone:507-235-3939
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-17
Last Update Date:2023-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical