Provider Demographics
NPI:1700854072
Name:SULLIVAN SURGICENTER,LLC
Entity Type:Organization
Organization Name:SULLIVAN SURGICENTER,LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:CUSTODIO
Authorized Official - Middle Name:L
Authorized Official - Last Name:LIM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:812-268-9000
Mailing Address - Street 1:320 N SECTION ST
Mailing Address - Street 2:
Mailing Address - City:SULLIVAN
Mailing Address - State:IN
Mailing Address - Zip Code:47882-1239
Mailing Address - Country:US
Mailing Address - Phone:812-268-9000
Mailing Address - Fax:812-268-8822
Practice Address - Street 1:320 N SECTION ST
Practice Address - Street 2:
Practice Address - City:SULLIVAN
Practice Address - State:IN
Practice Address - Zip Code:47882-1239
Practice Address - Country:US
Practice Address - Phone:812-268-9000
Practice Address - Fax:812-268-8822
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-10
Last Update Date:2012-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05-003633-1261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200503030Medicaid
INZR5090Medicare ID - Type Unspecified