Provider Demographics
NPI:1174528038
Name:AMBULATORY SURGERY CENTER OF ROSEBURG, LLC
Entity type:Organization
Organization Name:AMBULATORY SURGERY CENTER OF ROSEBURG, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF OPERATING OFFICER
Authorized Official - Prefix:DR
Authorized Official - First Name:VANESSA
Authorized Official - Middle Name:T
Authorized Official - Last Name:VU
Authorized Official - Suffix:
Authorized Official - Credentials:MD, PHD
Authorized Official - Phone:541-677-2800
Mailing Address - Street 1:2801 NW MERCY DR
Mailing Address - Street 2:STE 200
Mailing Address - City:ROSEBURG
Mailing Address - State:OR
Mailing Address - Zip Code:97470-2348
Mailing Address - Country:US
Mailing Address - Phone:541-677-2800
Mailing Address - Fax:541-677-2820
Practice Address - Street 1:2801 NW MERCY DR
Practice Address - Street 2:STE 200
Practice Address - City:ROSEBURG
Practice Address - State:OR
Practice Address - Zip Code:97470-2348
Practice Address - Country:US
Practice Address - Phone:541-677-2800
Practice Address - Fax:541-677-2820
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR07 1542261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR100343Medicaid
OR100343Medicaid