Provider Demographics
NPI:1447203161
Name:AMBULATORY SURGICAL CENTER OF STEVENS POINT LLC
Entity Type:Organization
Organization Name:AMBULATORY SURGICAL CENTER OF STEVENS POINT LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:R
Authorized Official - Last Name:FULLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:715-295-9939
Mailing Address - Street 1:500 VINCENT STREET
Mailing Address - Street 2:SUITE A
Mailing Address - City:STEVENS POINT
Mailing Address - State:WI
Mailing Address - Zip Code:54481-1842
Mailing Address - Country:US
Mailing Address - Phone:715-345-0500
Mailing Address - Fax:715-345-0400
Practice Address - Street 1:500 VINCENT STREET
Practice Address - Street 2:SUITE A
Practice Address - City:STEVENS POINT
Practice Address - State:WI
Practice Address - Zip Code:54481-1842
Practice Address - Country:US
Practice Address - Phone:715-345-0500
Practice Address - Fax:715-345-0400
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-17
Last Update Date:2012-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI30670500Medicaid
WI32144600Medicaid
WI32166500Medicaid
WI42986500Medicaid
WI31827000Medicaid
WI32144600Medicaid
F32274Medicare UPIN
F82806Medicare UPIN
000350105Medicare ID - Type Unspecified
WI31827000Medicaid
000150105Medicare ID - Type Unspecified
000250105Medicare ID - Type Unspecified
WI42986500Medicaid
G08462Medicare UPIN
000550105Medicare ID - Type Unspecified