Provider Demographics
NPI:1992037352
Name:BAYLOR SURGICARE AT MANSFIELD, LLC
Entity Type:Organization
Organization Name:BAYLOR SURGICARE AT MANSFIELD, LLC
Other - Org Name:BAYLOR SCOTT & WHITE SURGICARE - MANSFIELD
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICER/AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:PETER
Authorized Official - Middle Name:
Authorized Official - Last Name:BLACH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:713-343-0832
Mailing Address - Street 1:280 REGENCY PKWY
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:TX
Mailing Address - Zip Code:76063-7823
Mailing Address - Country:US
Mailing Address - Phone:817-453-2744
Mailing Address - Fax:817-842-0007
Practice Address - Street 1:280 REGENCY PKWY
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:TX
Practice Address - Zip Code:76063-7823
Practice Address - Country:US
Practice Address - Phone:817-453-2744
Practice Address - Fax:817-842-0007
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-09
Last Update Date:2021-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX130056261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXP00847625OtherRAILROAD MEDICARE PTAN
TXASC411Medicare PIN
TX45C0001486Medicare Oscar/Certification