Provider Demographics
NPI:1356395586
Name:PHYSICIANS SURGERY CENTER, LLC
Entity type:Organization
Organization Name:PHYSICIANS SURGERY CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:M.D. MANAGER - MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:H
Authorized Official - Last Name:CHARLTON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:801-277-2062
Mailing Address - Street 1:1485 E 3900 S
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84124-1412
Mailing Address - Country:US
Mailing Address - Phone:801-277-2062
Mailing Address - Fax:801-274-3233
Practice Address - Street 1:1485 E 3900 S
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84124-1412
Practice Address - Country:US
Practice Address - Phone:801-277-2062
Practice Address - Fax:801-274-3233
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-20
Last Update Date:2014-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT2006-ASF-74408261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical