Provider Demographics
NPI:1619998523
Name:UPSTATE SURGERY CENTER, LLC
Entity Type:Organization
Organization Name:UPSTATE SURGERY CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CONTROLLER
Authorized Official - Prefix:MR
Authorized Official - First Name:RAYMOND
Authorized Official - Middle Name:
Authorized Official - Last Name:MCCULLOCH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:864-282-4910
Mailing Address - Street 1:12670 CREEKSIDE LN STE 401
Mailing Address - Street 2:SUITE 401
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33919-3370
Mailing Address - Country:US
Mailing Address - Phone:239-274-1000
Mailing Address - Fax:239-274-1001
Practice Address - Street 1:10 ENTERPRISE BLVD
Practice Address - Street 2:SUITE 104
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29615-6301
Practice Address - Country:US
Practice Address - Phone:864-458-7141
Practice Address - Fax:864-676-9116
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-23
Last Update Date:2008-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCASF-050261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCASC028Medicaid
SCASC028Medicaid