Provider Demographics
NPI:1750499950
Name:MEDPLEX OUTPATIENT SURGERY CENTER LTD
Entity Type:Organization
Organization Name:MEDPLEX OUTPATIENT SURGERY CENTER LTD
Other - Org Name:MEDPLEX OUTPATIENT SURGERY CENTER
Other - Org Type:Other Name
Authorized Official - Title/Position:OFFICER / AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:JENETHA
Authorized Official - Middle Name:D
Authorized Official - Last Name:MORAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:972-763-3893
Mailing Address - Street 1:4511 SOUTHLAKE PKWY
Mailing Address - Street 2:
Mailing Address - City:HOOVER
Mailing Address - State:AL
Mailing Address - Zip Code:35244-3238
Mailing Address - Country:US
Mailing Address - Phone:205-985-4398
Mailing Address - Fax:205-444-1786
Practice Address - Street 1:4511 SOUTHLAKE PKWY
Practice Address - Street 2:
Practice Address - City:HOOVER
Practice Address - State:AL
Practice Address - Zip Code:35244-3238
Practice Address - Country:US
Practice Address - Phone:205-985-4398
Practice Address - Fax:205-444-1786
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-28
Last Update Date:2018-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALU5901261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ALASC-0014CMedicaid
AL000055048Medicare PIN
AL01C0001020Medicare Oscar/Certification