Provider Demographics
NPI:1801825955
Name:CONCHO SURGICAL PARTNERSHIP, LTD
Entity Type:Organization
Organization Name:CONCHO SURGICAL PARTNERSHIP, LTD
Other - Org Name:SHANNON SURGERY CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:CHUCK
Authorized Official - Middle Name:
Authorized Official - Last Name:DAWSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:325-486-5801
Mailing Address - Street 1:4482 SUNSET DR
Mailing Address - Street 2:
Mailing Address - City:SAN ANGELO
Mailing Address - State:TX
Mailing Address - Zip Code:76901-5611
Mailing Address - Country:US
Mailing Address - Phone:325-486-5800
Mailing Address - Fax:325-486-5850
Practice Address - Street 1:4482 SUNSET DR
Practice Address - Street 2:
Practice Address - City:SAN ANGELO
Practice Address - State:TX
Practice Address - Zip Code:76901-5611
Practice Address - Country:US
Practice Address - Phone:325-486-5800
Practice Address - Fax:325-486-5850
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-01
Last Update Date:2007-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX008290261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXASC273Medicare ID - Type Unspecified