Provider Demographics
NPI:1861492530
Name:GRANTS PASS SURGERY CENTER, LLC
Entity Type:Organization
Organization Name:GRANTS PASS SURGERY CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JULIE
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:DEGER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:541-472-4884
Mailing Address - Street 1:1601NW HAWTHORNE AVE
Mailing Address - Street 2:
Mailing Address - City:GRANTS PASS
Mailing Address - State:OR
Mailing Address - Zip Code:97526-1041
Mailing Address - Country:US
Mailing Address - Phone:541-472-4880
Mailing Address - Fax:541-472-4899
Practice Address - Street 1:1601 NW HAWTHORNE AVE
Practice Address - Street 2:
Practice Address - City:GRANTS PASS
Practice Address - State:OR
Practice Address - Zip Code:97526-1041
Practice Address - Country:US
Practice Address - Phone:541-472-4880
Practice Address - Fax:541-472-4899
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-26
Last Update Date:2008-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR0504365261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR165232Medicaid
ORR102579Medicare PIN