Provider Demographics
NPI:1750553376
Name:SAN MATEO SURGERY CENTER LLC
Entity type:Organization
Organization Name:SAN MATEO SURGERY CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:SONTAG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:650-570-0529
Mailing Address - Street 1:66 BOVET RD
Mailing Address - Street 2:SUITE 103
Mailing Address - City:SAN MATEO
Mailing Address - State:CA
Mailing Address - Zip Code:94402-3125
Mailing Address - Country:US
Mailing Address - Phone:650-570-0529
Mailing Address - Fax:
Practice Address - Street 1:66 BOVET RD
Practice Address - Street 2:SUITE 103
Practice Address - City:SAN MATEO
Practice Address - State:CA
Practice Address - Zip Code:94402-3125
Practice Address - Country:US
Practice Address - Phone:650-570-0529
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-25
Last Update Date:2015-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CABO043AMedicare PIN