Provider Demographics
NPI:1306836606
Name:SURGERY CENTER OF CLEVELAND
Entity Type:Organization
Organization Name:SURGERY CENTER OF CLEVELAND
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:CONNIE
Authorized Official - Middle Name:DELAINE
Authorized Official - Last Name:JONES
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:423-472-7874
Mailing Address - Street 1:137 25TH ST NE
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:TN
Mailing Address - Zip Code:37311-3944
Mailing Address - Country:US
Mailing Address - Phone:423-472-7874
Mailing Address - Fax:423-472-2881
Practice Address - Street 1:137 25TH ST NE
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:TN
Practice Address - Zip Code:37311-3944
Practice Address - Country:US
Practice Address - Phone:423-472-7874
Practice Address - Fax:423-472-2881
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-27
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0000000002261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN100920OtherBLUE CROSS PROVIDER NUMBE
TN7806130OtherAETNA PROVIDER NUMBER
TN3288386Medicare ID - Type UnspecifiedPROVIDER NUMBER