Provider Demographics
NPI:1811095136
Name:GROSSMONT OUTPATIENT SURGICAL CENTER
Entity type:Organization
Organization Name:GROSSMONT OUTPATIENT SURGICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:ROSE
Authorized Official - Middle Name:M
Authorized Official - Last Name:ELLIS
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:619-462-8620
Mailing Address - Street 1:5565 GROSSMONT CENTER DRIVE
Mailing Address - Street 2:BLDG. 3 SUITE 250
Mailing Address - City:LA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:91942-3026
Mailing Address - Country:US
Mailing Address - Phone:619-462-8620
Mailing Address - Fax:619-462-8621
Practice Address - Street 1:5565 GROSSMONT CENTER DRIVE
Practice Address - Street 2:BLDG. 3 SUITE 250
Practice Address - City:LA MESA
Practice Address - State:CA
Practice Address - Zip Code:91942-3026
Practice Address - Country:US
Practice Address - Phone:619-462-8620
Practice Address - Fax:619-462-8621
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAS551032Medicare ID - Type Unspecified