Provider Demographics
NPI:1740260926
Name:STARK AMBULATORY SURGERY CENTER, LLC
Entity type:Organization
Organization Name:STARK AMBULATORY SURGERY CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICER/AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:
Authorized Official - Last Name:HARTSHORN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-800-2017
Mailing Address - Street 1:4360 FULTON DR NW
Mailing Address - Street 2:SUITE C
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44718-2878
Mailing Address - Country:US
Mailing Address - Phone:330-305-2020
Mailing Address - Fax:330-305-2020
Practice Address - Street 1:4360 FULTON DR NW
Practice Address - Street 2:SUITE C
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44718-2878
Practice Address - Country:US
Practice Address - Phone:330-305-2020
Practice Address - Fax:330-305-2020
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-23
Last Update Date:2024-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH0750AS261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2533299Medicaid
OHST3611961Medicare ID - Type Unspecified