Provider Demographics
NPI:1487012480
Name:LAKE SPIVEY AMBULATORY SURGERY CARE, LLC
Entity Type:Organization
Organization Name:LAKE SPIVEY AMBULATORY SURGERY CARE, LLC
Other - Org Name:SPIVEY STATION SURGERY CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF COMPLIANCE COUNSEL
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:
Authorized Official - Last Name:DOAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:909-235-4307
Mailing Address - Street 1:11 UPPER RIVERDALE RD SW
Mailing Address - Street 2:
Mailing Address - City:RIVERDALE
Mailing Address - State:GA
Mailing Address - Zip Code:30274-2615
Mailing Address - Country:US
Mailing Address - Phone:770-991-8000
Mailing Address - Fax:
Practice Address - Street 1:7813 SPIVEY STATION BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:JONESBORO
Practice Address - State:GA
Practice Address - Zip Code:30236-2900
Practice Address - Country:US
Practice Address - Phone:770-268-6000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-04
Last Update Date:2016-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA031127261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA111125ASCAMedicare Oscar/Certification