Provider Demographics
NPI:1417958729
Name:MENTOR SURGERY CENTER LTD
Entity Type:Organization
Organization Name:MENTOR SURGERY CENTER LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS OFFICE MANAGER
Authorized Official - Prefix:MISS
Authorized Official - First Name:TRACY
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:PETERS
Authorized Official - Suffix:
Authorized Official - Credentials:CPC
Authorized Official - Phone:440-205-5467
Mailing Address - Street 1:9485 MENTOR AVE
Mailing Address - Street 2:STE 1
Mailing Address - City:MENTOR
Mailing Address - State:OH
Mailing Address - Zip Code:44060-8711
Mailing Address - Country:US
Mailing Address - Phone:440-205-5454
Mailing Address - Fax:440-205-5402
Practice Address - Street 1:9485 MENTOR AVE
Practice Address - Street 2:STE 1
Practice Address - City:MENTOR
Practice Address - State:OH
Practice Address - Zip Code:44060-4597
Practice Address - Country:US
Practice Address - Phone:440-205-5454
Practice Address - Fax:440-205-5402
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-09
Last Update Date:2014-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH0404AS261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2106143Medicaid
OH2106143Medicaid