Provider Demographics
NPI:1629045133
Name:MONTICELLO COMMUNITY SURGERY CENTER, LLC
Entity Type:Organization
Organization Name:MONTICELLO COMMUNITY SURGERY CENTER, LLC
Other - Org Name:UVA HEALTH SURGICAL CARE RIVERSIDE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:JESSIE
Authorized Official - Middle Name:
Authorized Official - Last Name:WAGNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:434-971-3406
Mailing Address - Street 1:2331 SEMINOLE LANE
Mailing Address - Street 2:SUITE 201
Mailing Address - City:CHARLOTTESVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22901-8319
Mailing Address - Country:US
Mailing Address - Phone:434-293-4995
Mailing Address - Fax:434-971-3434
Practice Address - Street 1:2331 SEMINOLE LANE
Practice Address - Street 2:SUITE 201
Practice Address - City:CHARLOTTESVILLE
Practice Address - State:VA
Practice Address - Zip Code:22901-8319
Practice Address - Country:US
Practice Address - Phone:434-293-4995
Practice Address - Fax:434-971-3434
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-02
Last Update Date:2023-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VAOH 662261QA1903X
261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAASC193Medicare ID - Type Unspecified