Provider Demographics
NPI:1588633184
Name:PREMIUM SURGERY CENTER LLC
Entity Type:Organization
Organization Name:PREMIUM SURGERY CENTER LLC
Other - Org Name:MERCY PREMIUM SURGERY CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:TITLE ADMIN
Authorized Official - Prefix:MS
Authorized Official - First Name:ROSE
Authorized Official - Middle Name:M
Authorized Official - Last Name:BEE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:440-937-5851
Mailing Address - Street 1:5319 HOAG DR
Mailing Address - Street 2:
Mailing Address - City:ELYRIA
Mailing Address - State:OH
Mailing Address - Zip Code:44035
Mailing Address - Country:US
Mailing Address - Phone:440-930-6042
Mailing Address - Fax:440-930-6105
Practice Address - Street 1:5319 HOAG DR
Practice Address - Street 2:
Practice Address - City:ELYRIA
Practice Address - State:OH
Practice Address - Zip Code:44035
Practice Address - Country:US
Practice Address - Phone:440-930-6042
Practice Address - Fax:440-930-6105
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-16
Last Update Date:2019-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH0572AS261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
000000338767OtherBLUE CROSS BLUE SHIELD
OH2213107Medicaid
P00124229OtherRR MEDICARE
OHPR3611402Medicare ID - Type Unspecified