Provider Demographics
NPI:1336202704
Name:SHERIDAN SURGICAL CENTER, LLC
Entity Type:Organization
Organization Name:SHERIDAN SURGICAL CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:CARTER
Authorized Official - Suffix:
Authorized Official - Credentials:BSN
Authorized Official - Phone:307-672-7874
Mailing Address - Street 1:1524 W 5TH ST
Mailing Address - Street 2:
Mailing Address - City:SHERIDAN
Mailing Address - State:WY
Mailing Address - Zip Code:82801-2707
Mailing Address - Country:US
Mailing Address - Phone:307-672-7874
Mailing Address - Fax:307-673-0655
Practice Address - Street 1:1524 W 5TH ST
Practice Address - Street 2:
Practice Address - City:SHERIDAN
Practice Address - State:WY
Practice Address - Zip Code:82801-2707
Practice Address - Country:US
Practice Address - Phone:307-672-7874
Practice Address - Fax:307-673-0655
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-18
Last Update Date:2008-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY07-012261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WYW20420Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER