Provider Demographics
NPI:1508846411
Name:FIRST STATE SURGERY CENTER, LLC
Entity Type:Organization
Organization Name:FIRST STATE SURGERY CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:RAYMOND
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:KRETT
Authorized Official - Suffix:JR
Authorized Official - Credentials:BSN
Authorized Official - Phone:302-683-0700
Mailing Address - Street 1:1000 TWIN C. LANE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:NEWARK
Mailing Address - State:DE
Mailing Address - Zip Code:19713
Mailing Address - Country:US
Mailing Address - Phone:302-683-0700
Mailing Address - Fax:302-683-0717
Practice Address - Street 1:1000 TWIN C LANE
Practice Address - Street 2:SUITE 200
Practice Address - City:NEWARK
Practice Address - State:DE
Practice Address - Zip Code:19713
Practice Address - Country:US
Practice Address - Phone:302-683-0700
Practice Address - Fax:302-683-0717
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-18
Last Update Date:2020-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
DEA00035Medicare ID - Type Unspecified
DE001182828Medicare ID - Type Unspecified