Provider Demographics
NPI:1508974353
Name:SOUTHLAKE AMBULATORY SURGERY CENTER, LLLP
Entity Type:Organization
Organization Name:SOUTHLAKE AMBULATORY SURGERY CENTER, LLLP
Other - Org Name:SPIVEY STATION SURGERY CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE VP & COO
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:R
Authorized Official - Last Name:MCLAIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-991-8000
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:770-897-8000
Mailing Address - Fax:770-268-6001
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:30236-0000
Practice Address - Country:US
Practice Address - Phone:770-268-6000
Practice Address - Fax:770-268-6001
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-29
Last Update Date:2013-07-25
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
GA00973046AMedicaid
GA306743Medicaid
GA00973046AMedicaid
GA111125ASCAMedicare ID - Type Unspecified