Provider Demographics
NPI:1013915685
Name:SURGERY CENTER OF DODGE CITY, LLC
Entity Type:Organization
Organization Name:SURGERY CENTER OF DODGE CITY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:DINA
Authorized Official - Middle Name:
Authorized Official - Last Name:LANE
Authorized Official - Suffix:
Authorized Official - Credentials:BSN
Authorized Official - Phone:620-408-9454
Mailing Address - Street 1:2203 SUMMERLON CIR
Mailing Address - Street 2:
Mailing Address - City:DODGE CITY
Mailing Address - State:KS
Mailing Address - Zip Code:67801-2985
Mailing Address - Country:US
Mailing Address - Phone:620-408-9454
Mailing Address - Fax:620-408-9552
Practice Address - Street 1:2203 SUMMERLON CIR
Practice Address - Street 2:
Practice Address - City:DODGE CITY
Practice Address - State:KS
Practice Address - Zip Code:67801-2985
Practice Address - Country:US
Practice Address - Phone:620-408-9454
Practice Address - Fax:620-408-9552
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KSS029001261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS112216Medicare ID - Type UnspecifiedPROVIDER NUMBER