Provider Demographics
NPI:1962583369
Name:FAMILY SURGERY CENTER, LLC
Entity type:Organization
Organization Name:FAMILY SURGERY CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:CARMEN
Authorized Official - Middle Name:
Authorized Official - Last Name:MACIK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:320-214-5759
Mailing Address - Street 1:1801 19TH AVE SW
Mailing Address - Street 2:
Mailing Address - City:WILLMAR
Mailing Address - State:MN
Mailing Address - Zip Code:56201-4946
Mailing Address - Country:US
Mailing Address - Phone:320-235-7700
Mailing Address - Fax:320-235-7701
Practice Address - Street 1:1801 19TH AVE SW
Practice Address - Street 2:
Practice Address - City:WILLMAR
Practice Address - State:MN
Practice Address - Zip Code:56201-4946
Practice Address - Country:US
Practice Address - Phone:320-235-7700
Practice Address - Fax:320-235-7701
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-18
Last Update Date:2012-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN330845207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN277A0FAOtherBCBS
MNC04245Medicare ID - Type Unspecified