| Organization Name: | STREET ROAD SURGERY CENTER, LLC |
| NPI Number: | 1134273311 |
| Entity Type Code: | Organizational (2) |
| Authorized Official Name: | EVELYN WITKIN (MEDICAL DIRECTOR) |
| Mailing Address: | 4979 Old Street Rd Trevose |
| State: | PA US |
| Postal Code: | 190536222 |
| Phone Number: | 2153557027 |
| Fax Number: | 2153557028 |
| NPI Enumeration Date: | 01/23/2007 |
| NPI Last Update Date: | 07/08/2007 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 261QA1903X |
| License Number: | 2053 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | PA |
| Taxonomy Type: | Ambulatory Health Care Facilities |
| Taxonomy Classification: | Clinic/Center |
| Taxonomy Specialization: | Ambulatory Surgical |
| Taxonomy Definition: | |