Organization
SOUTH SHORE SURGICENTER LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
CHARLES POLSEN M.D. (PROPRIETOR)
(281) 538-6600
Entity
Organization
Contact information
Practice address
2622 MARINA BAY DRIVE, LEAGUE CITY, TX 77573-6506
(281) 538-6600
(281) 535-2800
Mailing address
2622 MARINA BAY DRIVE, LEAGUE CITY, TX 77573-6506
(281) 538-6600
(281) 535-2800
Taxonomy
Speciality
Code
Description
License number
State
261QA1903X
Ambulatory Surgical Clinic/Center
Primary
130038
TX
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
OOO2CU
BLUE CROSS/BLUE SHIELD OF TEXAS PROVIDER ID
TX
Enumeration date
03/14/2007
Last updated
01/02/2013
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