Provider Demographics
NPI:1295820249
Name:NEW CEDAR LAKE SURGERY CENTER, LLC
Entity Type:Organization
Organization Name:NEW CEDAR LAKE SURGERY CENTER, LLC
Other - Org Name:THE SURGERY CENTER AT CEDAR LAKE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER AND DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:J
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:228-702-2000
Mailing Address - Street 1:1720 MEDICAL PARK DR # B
Mailing Address - Street 2:
Mailing Address - City:BILOXI
Mailing Address - State:MS
Mailing Address - Zip Code:39532-2131
Mailing Address - Country:US
Mailing Address - Phone:228-702-2000
Mailing Address - Fax:228-314-2589
Practice Address - Street 1:1720 MEDICAL PARK DR # B
Practice Address - Street 2:
Practice Address - City:BILOXI
Practice Address - State:MS
Practice Address - Zip Code:39532-2131
Practice Address - Country:US
Practice Address - Phone:228-702-2000
Practice Address - Fax:228-702-2019
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-04
Last Update Date:2017-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS004261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00770025Medicaid
MS490251003Medicare PIN