Provider Demographics
NPI:1821362443
Name:BLUE WAVE SURGERY CENTER, INC.
Entity Type:Organization
Organization Name:BLUE WAVE SURGERY CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ALEXANDER
Authorized Official - Middle Name:
Authorized Official - Last Name:SOROKURS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-622-5369
Mailing Address - Street 1:4910 VAN NUYS BLVD STE 306
Mailing Address - Street 2:
Mailing Address - City:SHERMAN OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91403-1770
Mailing Address - Country:US
Mailing Address - Phone:310-622-5369
Mailing Address - Fax:
Practice Address - Street 1:4910 VAN NUYS BLVD STE 306
Practice Address - Street 2:
Practice Address - City:SHERMAN OAKS
Practice Address - State:CA
Practice Address - Zip Code:91403-1770
Practice Address - Country:US
Practice Address - Phone:310-622-5369
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BLUE WAVE SURGERY CENTER, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-02-29
Last Update Date:2012-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA54193207Q00000X, 261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPTAN DH485ZMedicare PIN