Provider Demographics
NPI:1326256058
Name:MONTEREY PENNISULA SURGERY CENTER LLC
Entity Type:Organization
Organization Name:MONTEREY PENNISULA SURGERY CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:D
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:831-372-2169
Mailing Address - Street 1:2 UPPER RAGSDALE DR
Mailing Address - Street 2:BUILDING B, SUITE B160
Mailing Address - City:MONTEREY
Mailing Address - State:CA
Mailing Address - Zip Code:93940-5736
Mailing Address - Country:US
Mailing Address - Phone:831-372-2169
Mailing Address - Fax:
Practice Address - Street 1:2 UPPER RAGSDALE DR
Practice Address - Street 2:BUILDING B, SUITE B160
Practice Address - City:MONTEREY
Practice Address - State:CA
Practice Address - Zip Code:93940-5736
Practice Address - Country:US
Practice Address - Phone:831-372-2169
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-18
Last Update Date:2008-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA070000398261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASUR01028GMedicaid
CASUR01028GMedicaid