Provider Demographics
NPI:1326038100
Name:FOUNDATION SURGERY AFFILIATE OF THE MEDCENTER LLC
Entity Type:Organization
Organization Name:FOUNDATION SURGERY AFFILIATE OF THE MEDCENTER LLC
Other - Org Name:MEDCENTER AMBULATORY SURGERY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR/CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:RUTH
Authorized Official - Middle Name:A
Authorized Official - Last Name:MAXWELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:713-529-8600
Mailing Address - Street 1:2459 S BRAESWOOD BLVD
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77030-4305
Mailing Address - Country:US
Mailing Address - Phone:713-529-8600
Mailing Address - Fax:713-529-8603
Practice Address - Street 1:2459 S BRAESWOOD BLVD
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77030-4305
Practice Address - Country:US
Practice Address - Phone:713-529-8600
Practice Address - Fax:713-529-8603
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-24
Last Update Date:2009-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX7897261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1557670Medicaid
TX1557670Medicaid