Provider Demographics
NPI:1558613067
Name:AMBULATORY SURGERY CENTER AT THE JEFFERSON PAIN & REHAB CENTER
Entity type:Organization
Organization Name:AMBULATORY SURGERY CENTER AT THE JEFFERSON PAIN & REHAB CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:KEUN-SANG
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:412-885-5400
Mailing Address - Street 1:4735 CLAIRTON BLVD
Mailing Address - Street 2:
Mailing Address - City:PITTSBURGH
Mailing Address - State:PA
Mailing Address - Zip Code:15236-2115
Mailing Address - Country:US
Mailing Address - Phone:412-885-5400
Mailing Address - Fax:412-885-1773
Practice Address - Street 1:4735 CLAIRTON BLVD
Practice Address - Street 2:
Practice Address - City:PITTSBURGH
Practice Address - State:PA
Practice Address - Zip Code:15236-2115
Practice Address - Country:US
Practice Address - Phone:412-885-5400
Practice Address - Fax:412-885-1773
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-08
Last Update Date:2015-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0016772370001Medicaid
PA351687Medicare PIN