Provider Demographics
NPI:1659426385
Name:FORSYTH STREET AMBULATORY SURGERY CENTER, LLC
Entity Type:Organization
Organization Name:FORSYTH STREET AMBULATORY SURGERY CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:TAMMY
Authorized Official - Middle Name:MICHELLE
Authorized Official - Last Name:HODGE
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:478-749-1610
Mailing Address - Street 1:1610 FORSYTH STREET
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31201
Mailing Address - Country:US
Mailing Address - Phone:478-749-1610
Mailing Address - Fax:478-841-3150
Practice Address - Street 1:1610 FORSYTH STREET
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31201
Practice Address - Country:US
Practice Address - Phone:478-749-1610
Practice Address - Fax:478-841-3150
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-24
Last Update Date:2013-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAP00622117OtherRAILROAD MEDICARE
GA111304ASCAMedicare PIN