Provider Demographics
NPI:1912989526
Name:LINCOLN PARK SURGERY CENTER
Entity Type:Organization
Organization Name:LINCOLN PARK SURGERY CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:PALEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:937-424-5560
Mailing Address - Street 1:500 LINCOLN PARK BLVD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:KETTERING
Mailing Address - State:OH
Mailing Address - Zip Code:45429-3492
Mailing Address - Country:US
Mailing Address - Phone:937-424-5560
Mailing Address - Fax:937-424-5876
Practice Address - Street 1:500 LINCOLN PARK BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:KETTERING
Practice Address - State:OH
Practice Address - Zip Code:45429-3492
Practice Address - Country:US
Practice Address - Phone:937-424-5560
Practice Address - Fax:937-424-5876
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-18
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH0730AS261QA1903X
OH1073-1C261QR0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Not Answered261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2483638Medicaid
OH2483638Medicaid