Provider Demographics
NPI:1841286267
Name:SURGERY CENTER OF SOUTHERN OREGON, LLC
Entity type:Organization
Organization Name:SURGERY CENTER OF SOUTHERN OREGON, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXEC DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:WESTMILLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:541-858-8100
Mailing Address - Street 1:2798 E BARNETT RD
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-8343
Mailing Address - Country:US
Mailing Address - Phone:541-858-8100
Mailing Address - Fax:541-858-0102
Practice Address - Street 1:2798 E BARNETT RD
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-8343
Practice Address - Country:US
Practice Address - Phone:541-858-8100
Practice Address - Fax:541-858-0102
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-21
Last Update Date:2013-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR07-1509261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR165630Medicaid
OR165630Medicaid