Provider Demographics
NPI:1508863085
Name:SPRING CREEK MEDICAL PARK OUTPATIENT SURGERY CENTER LLC
Entity Type:Organization
Organization Name:SPRING CREEK MEDICAL PARK OUTPATIENT SURGERY CENTER LLC
Other - Org Name:SPRING CREEK SURGERY CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JACK
Authorized Official - Middle Name:
Authorized Official - Last Name:BURGIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:970-232-1717
Mailing Address - Street 1:2001 S SHIELDS ST
Mailing Address - Street 2:BLDG F
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80526-1827
Mailing Address - Country:US
Mailing Address - Phone:970-232-1717
Mailing Address - Fax:970-488-3950
Practice Address - Street 1:2001 S SHIELDS ST
Practice Address - Street 2:BLDG F
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80526-1827
Practice Address - Country:US
Practice Address - Phone:970-232-1717
Practice Address - Fax:970-488-3950
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-30
Last Update Date:2010-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0110261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO04510251Medicaid
COCA61031Medicare ID - Type UnspecifiedPROVIDER NUMBER