Provider Demographics
NPI:1912240003
Name:ELO OUTPATIENT SURGERY CENTER LLC
Entity Type:Organization
Organization Name:ELO OUTPATIENT SURGERY CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:NNAEMEKA
Authorized Official - Middle Name:M
Authorized Official - Last Name:UMERAH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:478-746-2888
Mailing Address - Street 1:840 PINE STREET
Mailing Address - Street 2:900
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31201-5100
Mailing Address - Country:US
Mailing Address - Phone:478-746-2888
Mailing Address - Fax:478-746-2889
Practice Address - Street 1:4050 RIVERSIDE DR
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31210-1805
Practice Address - Country:US
Practice Address - Phone:478-746-2888
Practice Address - Fax:478-746-2889
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-03-27
Last Update Date:2013-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA63974261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003000004BMedicaid
GA003000004BMedicaid