Provider Demographics
NPI:1659313930
Name:MADISON AMBULATORY SURGERY CENTER, LLC
Entity Type:Organization
Organization Name:MADISON AMBULATORY SURGERY CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ANDREA
Authorized Official - Middle Name:
Authorized Official - Last Name:MARTELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:360-402-1433
Mailing Address - Street 1:1883 HIGHWAY 43 S
Mailing Address - Street 2:SUITE J
Mailing Address - City:CANTON
Mailing Address - State:MS
Mailing Address - Zip Code:39046-8405
Mailing Address - Country:US
Mailing Address - Phone:601-942-7254
Mailing Address - Fax:
Practice Address - Street 1:1883 HIGHWAY 43 S
Practice Address - Street 2:SUITE J
Practice Address - City:CANTON
Practice Address - State:MS
Practice Address - Zip Code:39046-8405
Practice Address - Country:US
Practice Address - Phone:601-942-7254
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-12
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPENDING261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical