Provider Demographics
NPI:1407853740
Name:NORTHEAST BAPTIST SURGERY CENTER LLC
Entity Type:Organization
Organization Name:NORTHEAST BAPTIST SURGERY CENTER LLC
Other - Org Name:VILLAGE SPECIALTY SURGICAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MISS
Authorized Official - First Name:MISTY
Authorized Official - Middle Name:DIANE
Authorized Official - Last Name:WALTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:210-477-1788
Mailing Address - Street 1:8715 VILLAGE DR
Mailing Address - Street 2:SUITE 200
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78217
Mailing Address - Country:US
Mailing Address - Phone:210-477-1775
Mailing Address - Fax:210-477-1794
Practice Address - Street 1:8715 VILLAGE DR
Practice Address - Street 2:SUITE 200
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78217
Practice Address - Country:US
Practice Address - Phone:210-477-1775
Practice Address - Fax:210-477-1794
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-01
Last Update Date:2009-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX000369261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX490003869OtherRAILROAD MEDICARE
TX087944701Medicaid
TX490003869OtherRAILROAD MEDICARE
TX087944701Medicaid