Provider Demographics
NPI:1477645711
Name:PROGRESSIVE SURGERY CENTER LLC
Entity Type:Organization
Organization Name:PROGRESSIVE SURGERY CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:KENDEL
Authorized Official - Middle Name:D
Authorized Official - Last Name:MCKENNA
Authorized Official - Suffix:
Authorized Official - Credentials:MHA
Authorized Official - Phone:631-694-0000
Mailing Address - Street 1:340 BROADHOLLOW RD
Mailing Address - Street 2:
Mailing Address - City:FARMINGDALE
Mailing Address - State:NY
Mailing Address - Zip Code:11735-4807
Mailing Address - Country:US
Mailing Address - Phone:631-694-0000
Mailing Address - Fax:631-694-2470
Practice Address - Street 1:340 BROADHOLLOW RD
Practice Address - Street 2:
Practice Address - City:FARMINGDALE
Practice Address - State:NY
Practice Address - Zip Code:11735-4807
Practice Address - Country:US
Practice Address - Phone:631-694-0000
Practice Address - Fax:631-694-2470
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-28
Last Update Date:2012-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY5150202R261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02490288Medicaid
NY02490288Medicaid