Provider Demographics
NPI:1255503553
Name:WILLOUGHBY SURGERY CENTER, LLC
Entity Type:Organization
Organization Name:WILLOUGHBY SURGERY CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:A
Authorized Official - Last Name:DEMANGONE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:440-944-1414
Mailing Address - Street 1:6025 COMMERCE CIR
Mailing Address - Street 2:SUITE 1
Mailing Address - City:WILLOUGHBY
Mailing Address - State:OH
Mailing Address - Zip Code:44094-9668
Mailing Address - Country:US
Mailing Address - Phone:440-585-2750
Mailing Address - Fax:440-944-0868
Practice Address - Street 1:6025 COMMERCE CIR
Practice Address - Street 2:SUITE 1
Practice Address - City:WILLOUGHBY
Practice Address - State:OH
Practice Address - Zip Code:44094-9668
Practice Address - Country:US
Practice Address - Phone:440-585-2750
Practice Address - Fax:440-944-0868
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-26
Last Update Date:2013-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHP00829745OtherRAILROAD MEDICARE
OH3137920Medicaid
OH3612561Medicare PIN