Provider Demographics
NPI:1356444863
Name:ST GEORGE SURGICAL CENTER LP
Entity Type:Organization
Organization Name:ST GEORGE SURGICAL CENTER LP
Other - Org Name:ST GEORGE SURGICAL ANESTHESIA GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:CORLAND
Authorized Official - Middle Name:TY
Authorized Official - Last Name:TIPPETS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:435-673-8080
Mailing Address - Street 1:676 S BLUFF ST
Mailing Address - Street 2:
Mailing Address - City:ST GEORGE
Mailing Address - State:UT
Mailing Address - Zip Code:84770-3596
Mailing Address - Country:US
Mailing Address - Phone:435-673-8080
Mailing Address - Fax:435-673-0096
Practice Address - Street 1:676 S BLUFF ST
Practice Address - Street 2:
Practice Address - City:ST GEORGE
Practice Address - State:UT
Practice Address - Zip Code:84770-3596
Practice Address - Country:US
Practice Address - Phone:435-673-8080
Practice Address - Fax:435-673-0096
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ST. GEORGE SURGICAL CENTER, L.P.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-09-07
Last Update Date:2014-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5566449-1205207LP2900X
261QA1903X, 261QA1903X
UT6160962-1205207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory SurgicalGroup - Multi-Specialty
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Multi-Specialty
No207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
0100080Medicare ID - Type Unspecified