Provider Demographics
NPI:1700966710
Name:SURGERY CENTER OF KALAMAZOO LLC
Entity Type:Organization
Organization Name:SURGERY CENTER OF KALAMAZOO LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICER AND AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:BOYD
Authorized Official - Last Name:BALDOCK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-234-5954
Mailing Address - Street 1:3200 W CENTRE AVE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:PORTAGE
Mailing Address - State:MI
Mailing Address - Zip Code:49024-4889
Mailing Address - Country:US
Mailing Address - Phone:269-323-9905
Mailing Address - Fax:
Practice Address - Street 1:3200 W CENTRE AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:PORTAGE
Practice Address - State:MI
Practice Address - Zip Code:49024-4889
Practice Address - Country:US
Practice Address - Phone:269-323-9905
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-16
Last Update Date:2023-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0P11530Medicare ID - Type Unspecified