Foundation Surgery Affiliates

Tell us more about your facility

Facility Name

Facility Address

Facility Address

City

State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Zip

Facility Website

Number of Physician Partners

Estimated Number of Monthly Surgical Procedures

Do you currently have a corporate partner? Yes No

Do you currently have a hospital partner? Yes No

Facility Payer Mix (estimate)

% Medicare
% Medicaid
% Commerical
% Other