Provider Demographics
NPI:1013089127
Name:PORT ARTHUR DAY SURGERY CENTER LTD
Entity Type:Organization
Organization Name:PORT ARTHUR DAY SURGERY CENTER LTD
Other - Org Name:AMBULATORY SURGICAL CENTER
Other - Org Type:Other Name
Authorized Official - Title/Position:CHAIRMAN
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:A
Authorized Official - Last Name:ICETON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:409-983-6144
Mailing Address - Street 1:PO BOX 3915
Mailing Address - Street 2:3449 GATES BOULEVARD
Mailing Address - City:PORT ARTHUR
Mailing Address - State:TX
Mailing Address - Zip Code:77642
Mailing Address - Country:US
Mailing Address - Phone:409-983-6144
Mailing Address - Fax:409-983-2739
Practice Address - Street 1:3449 GATES BOULEVARD
Practice Address - Street 2:
Practice Address - City:PORT ARTHUR
Practice Address - State:TX
Practice Address - Zip Code:77642
Practice Address - Country:US
Practice Address - Phone:409-983-6144
Practice Address - Fax:409-983-2739
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX000155261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX451055Medicare ID - Type Unspecified