Provider Demographics
NPI:1265495451
Name:EXECUTIVE WOODS AMBULATORY SURGERY CENTER LLC
Entity type:Organization
Organization Name:EXECUTIVE WOODS AMBULATORY SURGERY CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:KYLE
Authorized Official - Middle Name:R
Authorized Official - Last Name:FLIK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:518-453-2361
Mailing Address - Street 1:3 ATRIUM DR
Mailing Address - Street 2:SUITE 150
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12205-1417
Mailing Address - Country:US
Mailing Address - Phone:518-453-2361
Mailing Address - Fax:518-453-1594
Practice Address - Street 1:3 ATRIUM DR
Practice Address - Street 2:SUITE 150
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12205-1417
Practice Address - Country:US
Practice Address - Phone:518-453-2361
Practice Address - Fax:518-453-1594
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-10
Last Update Date:2025-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0101219R261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY000401075000OtherBSNENY PROVIDER NUMBER
NY10043997OtherCDPHP PROVIDER NUMBER
NY02107211Medicaid
NY014594OtherEMPIRE BC PROVIDER NUMBER
NY1488OtherMVP PROVIDER NUMBER
NY000401075000OtherBSNENY PROVIDER NUMBER