Provider Demographics
NPI:1235193988
Name:SAME DAY SURGERY OF LATHAM INC
Entity Type:Organization
Organization Name:SAME DAY SURGERY OF LATHAM INC
Other - Org Name:CENTURY SAME DAY SURGERY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:BRAD
Authorized Official - Middle Name:NEAL
Authorized Official - Last Name:OTTWELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:636-549-2381
Mailing Address - Street 1:PO BOX 79033
Mailing Address - Street 2:
Mailing Address - City:ST LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63179-0333
Mailing Address - Country:US
Mailing Address - Phone:636-938-6868
Mailing Address - Fax:636-938-1486
Practice Address - Street 1:7 CENTURY HILL DR
Practice Address - Street 2:
Practice Address - City:LATHAM
Practice Address - State:NY
Practice Address - Zip Code:12110
Practice Address - Country:US
Practice Address - Phone:518-785-5741
Practice Address - Fax:518-785-8134
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-12
Last Update Date:2008-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY4410261QA1903X
NY0153202R261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01238504Medicaid
NY52481BMedicare PIN