Provider Demographics
NPI:1609376409
Name:KOKOMO AMBULATORY SURGERY CENTER
Entity Type:Organization
Organization Name:KOKOMO AMBULATORY SURGERY CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SHAZIA
Authorized Official - Middle Name:M
Authorized Official - Last Name:SIDDIQUI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:765-450-6735
Mailing Address - Street 1:PO BOX 5748
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47903-5748
Mailing Address - Country:US
Mailing Address - Phone:765-714-4344
Mailing Address - Fax:
Practice Address - Street 1:107 S WASHINGTON ST STE A
Practice Address - Street 2:
Practice Address - City:KOKOMO
Practice Address - State:IN
Practice Address - Zip Code:46901-4601
Practice Address - Country:US
Practice Address - Phone:765-450-6735
Practice Address - Fax:765-838-3200
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-02-19
Last Update Date:2018-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical