Provider Demographics
NPI:1518129576
Name:USC AMBULATORY SURGICAL CENTER PROF LLC
Entity Type:Organization
Organization Name:USC AMBULATORY SURGICAL CENTER PROF LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:TAMI
Authorized Official - Middle Name:
Authorized Official - Last Name:GRONSETH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:605-336-0635
Mailing Address - Street 1:201 WEST 69TH STREET
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57108-2424
Mailing Address - Country:US
Mailing Address - Phone:605-336-0635
Mailing Address - Fax:
Practice Address - Street 1:201 WEST 69TH STREET
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57108-2424
Practice Address - Country:US
Practice Address - Phone:605-336-0635
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-30
Last Update Date:2009-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD1518129576OtherBCBS
SD5490500Medicaid
P00729337OtherRAILROAD MEDICARE
IA1518129576Medicaid
MN1518129576OtherBLUE SHIELD OF MN
MN1518129576Medicaid
SDS102626Medicare PIN