Provider Demographics
NPI:1972508174
Name:VILLAGE SURGICENTER, LIMITED PARTNERSHIP
Entity Type:Organization
Organization Name:VILLAGE SURGICENTER, LIMITED PARTNERSHIP
Other - Org Name:VILLAGE SURGICENTER OF ERIE
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:B
Authorized Official - Last Name:BALDOCK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-234-5954
Mailing Address - Street 1:5473 VILLAGE COMMON DR
Mailing Address - Street 2:STE 100
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16506-4961
Mailing Address - Country:US
Mailing Address - Phone:814-836-0770
Mailing Address - Fax:814-836-0771
Practice Address - Street 1:5473 VILLAGE COMMON DR
Practice Address - Street 2:STE 100
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16506-4961
Practice Address - Country:US
Practice Address - Phone:814-836-0770
Practice Address - Fax:814-836-0771
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-15
Last Update Date:2023-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA11001500261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0017687800002Medicaid
PA391082Medicare ID - Type UnspecifiedHCFA ISSUED ID NUMBER
PA0017687800002Medicaid