Provider Demographics
NPI:1649489832
Name:FREMONT SURGICAL CENTER, LLC
Entity type:Organization
Organization Name:FREMONT SURGICAL CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:P
Authorized Official - Last Name:HENRY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:402-941-7050
Mailing Address - Street 1:840 E 29TH STREET
Mailing Address - Street 2:
Mailing Address - City:FREMONT
Mailing Address - State:NE
Mailing Address - Zip Code:68025
Mailing Address - Country:US
Mailing Address - Phone:402-941-7050
Mailing Address - Fax:402-941-7055
Practice Address - Street 1:840 E 29TH STREET
Practice Address - Street 2:
Practice Address - City:FREMONT
Practice Address - State:NE
Practice Address - Zip Code:68025
Practice Address - Country:US
Practice Address - Phone:402-941-7050
Practice Address - Fax:402-941-7055
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-22
Last Update Date:2010-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE261QA1903X
NEASC052261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE10025569200Medicaid
NE10025569200Medicaid