Provider Demographics
NPI:1679595680
Name:SURGERY CENTER OF LEBANON, LP
Entity Type:Organization
Organization Name:SURGERY CENTER OF LEBANON, LP
Other - Org Name:PHYSICIANS SURGICAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICER AND AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:BOYD
Authorized Official - Last Name:BALDOCK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-234-5954
Mailing Address - Street 1:1840 QUENTIN RD
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:PA
Mailing Address - Zip Code:17042-7436
Mailing Address - Country:US
Mailing Address - Phone:717-272-0007
Mailing Address - Fax:717-675-2247
Practice Address - Street 1:1840 QUENTIN RD
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:PA
Practice Address - Zip Code:17042-7436
Practice Address - Country:US
Practice Address - Phone:717-272-0007
Practice Address - Fax:717-675-2247
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-25
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA1893261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1893OtherDOH LICENSURE NUMBER
PA101425401Medicaid
PABM9228847OtherDEA NUMBER