Provider Demographics
NPI:1720023690
Name:BLUE WATER ASC LLC
Entity Type:Organization
Organization Name:BLUE WATER ASC LLC
Other - Org Name:BLUE WATER SURGERY CENTER, LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:
Authorized Official - Last Name:SNODGRASS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-665-1283
Mailing Address - Street 1:920 RIVER CENTRE DR
Mailing Address - Street 2:
Mailing Address - City:PORT HURON
Mailing Address - State:MI
Mailing Address - Zip Code:48060-4463
Mailing Address - Country:US
Mailing Address - Phone:810-984-5200
Mailing Address - Fax:810-985-5050
Practice Address - Street 1:920 RIVER CENTRE DR
Practice Address - Street 2:
Practice Address - City:PORT HURON
Practice Address - State:MI
Practice Address - Zip Code:48060-4463
Practice Address - Country:US
Practice Address - Phone:810-984-5200
Practice Address - Fax:810-985-5050
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-17
Last Update Date:2022-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI74-6817261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIOP32660Medicare PIN
MI23-C0001067Medicare Oscar/Certification