Provider Demographics
NPI:1407307820
Name:SURGICAL CENTER OF GREENSBORO LLC
Entity Type:Organization
Organization Name:SURGICAL CENTER OF GREENSBORO LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF ADMINISTRATIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:GRAHAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-272-0012
Mailing Address - Street 1:705 GREEN VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27408-7019
Mailing Address - Country:US
Mailing Address - Phone:336-272-0012
Mailing Address - Fax:336-544-2150
Practice Address - Street 1:705 GREEN VALLEY RD
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27408-7019
Practice Address - Country:US
Practice Address - Phone:336-272-0012
Practice Address - Fax:336-544-2150
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-20
Last Update Date:2019-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCAS0018261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC3409923Medicaid
NC2380820Medicare Oscar/Certification