Provider Demographics
NPI:1255317384
Name:GOOD SHEPHERD AMBULATORY SURGICAL CENTER LTD
Entity Type:Organization
Organization Name:GOOD SHEPHERD AMBULATORY SURGICAL CENTER LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:D
Authorized Official - Last Name:ADAIR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:903-315-2000
Mailing Address - Street 1:703 E MARSHALL AVE
Mailing Address - Street 2:SUITE 2000
Mailing Address - City:LONGVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:75601-5500
Mailing Address - Country:US
Mailing Address - Phone:903-315-5300
Mailing Address - Fax:903-315-5301
Practice Address - Street 1:703 E MARSHALL AVE
Practice Address - Street 2:SUITE 2000
Practice Address - City:LONGVIEW
Practice Address - State:TX
Practice Address - Zip Code:75601-5500
Practice Address - Country:US
Practice Address - Phone:903-315-5300
Practice Address - Fax:903-315-5301
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-20
Last Update Date:2009-05-13
Deactivation Date:2009-03-24
Deactivation Code:
Reactivation Date:2009-05-13
Provider Licenses
StateLicense IDTaxonomies
TX7792261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX122076OtherCHIPS/SUPERIOR HEALTH PLA
TXHH1354OtherBCBS OF TEXAS
TX147239101Medicaid
TX147239101Medicaid
TXHH1354OtherBCBS OF TEXAS
TXASC120Medicare ID - Type Unspecified