Provider Demographics
NPI:1336128479
Name:SOUTHWEST SURGICAL PARTNERS LLC
Entity Type:Organization
Organization Name:SOUTHWEST SURGICAL PARTNERS LLC
Other - Org Name:BEAVERCREEK SURGERY CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:
Authorized Official - Last Name:GAULT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:937-458-4201
Mailing Address - Street 1:3559 KEMP RD
Mailing Address - Street 2:SUITE 120
Mailing Address - City:BEAVERCREEK
Mailing Address - State:OH
Mailing Address - Zip Code:45431-2533
Mailing Address - Country:US
Mailing Address - Phone:937-458-4100
Mailing Address - Fax:937-458-4119
Practice Address - Street 1:3559 KEMP RD
Practice Address - Street 2:SUITE 120
Practice Address - City:BEAVERCREEK
Practice Address - State:OH
Practice Address - Zip Code:45431-2533
Practice Address - Country:US
Practice Address - Phone:937-458-4100
Practice Address - Fax:937-458-4119
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH0558AS261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2139948Medicaid
OH3611281Medicare ID - Type Unspecified