Provider Demographics
NPI:1467468603
Name:MEMORIAL AMBULATORY SURGERY CENTER
Entity Type:Organization
Organization Name:MEMORIAL AMBULATORY SURGERY CENTER
Other - Org Name:MEMORIAL AMBULATORY SURGERY CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DANIELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:NUGENT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:804-287-7881
Mailing Address - Street 1:8262 ATLEE RD STE 100
Mailing Address - Street 2:
Mailing Address - City:MECHANICSVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:23116-1816
Mailing Address - Country:US
Mailing Address - Phone:804-746-6969
Mailing Address - Fax:804-746-6950
Practice Address - Street 1:8262 ATLEE ROAD, MOB III, SUITE #100
Practice Address - Street 2:
Practice Address - City:MECHANICSVILLE
Practice Address - State:VA
Practice Address - Zip Code:23116
Practice Address - Country:US
Practice Address - Phone:804-746-6969
Practice Address - Fax:804-746-6950
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-31
Last Update Date:2012-01-04
Deactivation Date:2011-04-28
Deactivation Code:
Reactivation Date:2011-12-29
Provider Licenses
StateLicense IDTaxonomies
VAOH696261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA192949763Medicare PIN