Provider Demographics
NPI:1154308880
Name:WOODBURY AMBULATORY SURGERY CENTER, LLC
Entity Type:Organization
Organization Name:WOODBURY AMBULATORY SURGERY CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF SURGERY CENTERS
Authorized Official - Prefix:
Authorized Official - First Name:BECKIE
Authorized Official - Middle Name:
Authorized Official - Last Name:HINES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:651-968-5438
Mailing Address - Street 1:8675 VALLEY CREEK RD STE 300
Mailing Address - Street 2:
Mailing Address - City:WOODBURY
Mailing Address - State:MN
Mailing Address - Zip Code:55125-2337
Mailing Address - Country:US
Mailing Address - Phone:651-241-3450
Mailing Address - Fax:651-241-3453
Practice Address - Street 1:8675 VALLEY CREEK RD STE 300
Practice Address - Street 2:
Practice Address - City:WOODBURY
Practice Address - State:MN
Practice Address - Zip Code:55125-2337
Practice Address - Country:US
Practice Address - Phone:651-241-3450
Practice Address - Fax:651-241-3453
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-23
Last Update Date:2016-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN375356261QA1903X
MN356039261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN6801155OtherMEDICA
MN8D10WOOtherBLUE CROSS BLUE SHIELD
MN392145000Medicaid
MN64010OtherHEALTHPARTNERS
MN490000025Medicare ID - Type Unspecified