Provider Demographics
NPI:1043254063
Name:SIERRA AMBULATORY SURGERY CENTER
Entity type:Organization
Organization Name:SIERRA AMBULATORY SURGERY CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:EDWARD
Authorized Official - Last Name:HAGELE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:530-272-3411
Mailing Address - Street 1:400 SIERRA COLLEGE DRIVE
Mailing Address - Street 2:SUITE B
Mailing Address - City:GRASS VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:95945-5089
Mailing Address - Country:US
Mailing Address - Phone:530-272-3428
Mailing Address - Fax:530-272-3429
Practice Address - Street 1:400 SIERRA COLLEGE DRIVE
Practice Address - Street 2:SUITE B
Practice Address - City:GRASS VALLEY
Practice Address - State:CA
Practice Address - Zip Code:95945-5089
Practice Address - Country:US
Practice Address - Phone:530-272-3428
Practice Address - Fax:530-272-3429
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-16
Last Update Date:2012-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA550000155261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA550000155OtherSTATE LICENSE NUMBER
CA05C0001760Medicare ID - Type UnspecifiedPROVIDER NUMBER