Provider Demographics
NPI:1881684538
Name:MCPEAK SURGERY CENTER LLC
Entity Type:Organization
Organization Name:MCPEAK SURGERY CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SPENCER
Authorized Official - Middle Name:
Authorized Official - Last Name:WITCHER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:270-651-2181
Mailing Address - Street 1:108 BRAVO BLVD
Mailing Address - Street 2:
Mailing Address - City:GLASGOW
Mailing Address - State:KY
Mailing Address - Zip Code:42141-3478
Mailing Address - Country:US
Mailing Address - Phone:270-651-2181
Mailing Address - Fax:270-651-2183
Practice Address - Street 1:108 BRAVO BLVD
Practice Address - Street 2:
Practice Address - City:GLASGOW
Practice Address - State:KY
Practice Address - Zip Code:42141-3478
Practice Address - Country:US
Practice Address - Phone:270-651-2181
Practice Address - Fax:270-651-2183
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-25
Last Update Date:2017-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY300060261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY36000826Medicaid
KY36000826Medicaid