Provider Demographics
NPI:1841688942
Name:WESTERN AVENUE DAY SURGERY CENTER
Entity type:Organization
Organization Name:WESTERN AVENUE DAY SURGERY CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:E
Authorized Official - Last Name:VAUGHAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:207-775-3446
Mailing Address - Street 1:244 WESTERN AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04106-2430
Mailing Address - Country:US
Mailing Address - Phone:207-775-3446
Mailing Address - Fax:207-879-4188
Practice Address - Street 1:244 WESTERN AVE
Practice Address - Street 2:
Practice Address - City:SOUTH PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04106-2430
Practice Address - Country:US
Practice Address - Phone:207-775-3446
Practice Address - Fax:207-879-4188
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-26
Last Update Date:2021-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME38157261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME107150200Medicaid
MEWE201001Medicare UPIN