Provider Demographics
NPI:1710207998
Name:PROVIDENCE SURGERY CENTERS LLC
Entity Type:Organization
Organization Name:PROVIDENCE SURGERY CENTERS LLC
Other - Org Name:CREEKSIDE SURGICAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SECRETARY, BOARD OF MANAGERS
Authorized Official - Prefix:
Authorized Official - First Name:COLLEEN
Authorized Official - Middle Name:M
Authorized Official - Last Name:BRIDGE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:907-212-3035
Mailing Address - Street 1:PO BOX 233889
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99523-3889
Mailing Address - Country:US
Mailing Address - Phone:907-212-3035
Mailing Address - Fax:315-571-9944
Practice Address - Street 1:3831 PIPER ST. SUITE S-110
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99508
Practice Address - Country:US
Practice Address - Phone:907-339-7800
Practice Address - Fax:315-571-9944
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-10
Last Update Date:2010-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AKPENDING261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK000000000OtherPENDING MEDICARE #