Provider Demographics
NPI:1669039640
Name:BLACK ROCK SURGERY CENTER LLC
Entity Type:Organization
Organization Name:BLACK ROCK SURGERY CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:G
Authorized Official - Last Name:MURPHY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:307-358-6200
Mailing Address - Street 1:PO BOX 688
Mailing Address - Street 2:
Mailing Address - City:DOUGLAS
Mailing Address - State:WY
Mailing Address - Zip Code:82633-0688
Mailing Address - Country:US
Mailing Address - Phone:307-358-6200
Mailing Address - Fax:307-358-3748
Practice Address - Street 1:2901 POWDER BASIN AVE
Practice Address - Street 2:
Practice Address - City:GILLETTE
Practice Address - State:WY
Practice Address - Zip Code:82718-6406
Practice Address - Country:US
Practice Address - Phone:307-682-6222
Practice Address - Fax:307-682-6999
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-05-24
Last Update Date:2019-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
No261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty