Provider Demographics
NPI:1821411885
Name:ST. RAPHAEL'S SURGERY CENTER LLC
Entity Type:Organization
Organization Name:ST. RAPHAEL'S SURGERY CENTER LLC
Other - Org Name:ST. RAPHAEL'S SURGERY CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICER AND AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:BOYD
Authorized Official - Last Name:BALDOCK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-234-5900
Mailing Address - Street 1:18518 HARDY OAK BLVD
Mailing Address - Street 2:SUITE #100
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78258
Mailing Address - Country:US
Mailing Address - Phone:210-880-9897
Mailing Address - Fax:210-855-8432
Practice Address - Street 1:18518 HARDY OAK BOULEVARD
Practice Address - Street 2:SUITE #100
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78258
Practice Address - Country:US
Practice Address - Phone:210-880-9897
Practice Address - Fax:210-855-8432
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-28
Last Update Date:2020-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QA1903X
TX130183261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical