Provider Demographics
NPI:1942697735
Name:SOUTH OMAHA SURGICAL CENTER LLC
Entity Type:Organization
Organization Name:SOUTH OMAHA SURGICAL CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:W
Authorized Official - Last Name:BORVAN
Authorized Official - Suffix:
Authorized Official - Credentials:CRNA
Authorized Official - Phone:708-253-7258
Mailing Address - Street 1:21120 WASHINGTON PKWY
Mailing Address - Street 2:
Mailing Address - City:FRANKFORT
Mailing Address - State:IL
Mailing Address - Zip Code:60423-3112
Mailing Address - Country:US
Mailing Address - Phone:815-469-9750
Mailing Address - Fax:815-469-9752
Practice Address - Street 1:3201 S 24TH ST
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68108-1825
Practice Address - Country:US
Practice Address - Phone:402-504-4071
Practice Address - Fax:402-504-4124
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-20
Last Update Date:2017-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NEASC068261QA1903X
261QM1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
No261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty