Provider Demographics
NPI:1538122957
Name:SURGERY CENTER OF CINCINNATI, LLC
Entity Type:Organization
Organization Name:SURGERY CENTER OF CINCINNATI, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:VIRGIL
Authorized Official - Middle Name:RAY
Authorized Official - Last Name:CANTRELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:513-947-1130
Mailing Address - Street 1:4415 AICHOLTZ RD
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45245-1506
Mailing Address - Country:US
Mailing Address - Phone:513-947-1130
Mailing Address - Fax:513-947-8541
Practice Address - Street 1:4415 AICHOLTZ RD
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45245-1506
Practice Address - Country:US
Practice Address - Phone:513-947-1130
Practice Address - Fax:513-947-8541
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-07
Last Update Date:2011-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH0587AS261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY36000123Medicaid
OH2185102Medicaid
KY375674700OtherKENTUCKY WORKERS COMP
IN200292830AMedicaid
OH000000156597OtherANTHEM PROVIDER ID
OH61101OtherHUMANA PROVIDER ID
KY36000123Medicaid
KY36000123Medicaid