MEDICARE: MR. JOHN CREEKMORE SA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	246ZC0007X	Surgical Assistant	3155	OH

General Provider Information

NPI Number	:	1043508229
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JOHN CREEKMORE SA-C

Provider Business Mailing Address
First Line	:	8000 WATERFORD TIDE LOOP
Second Line	:	#2931
City	:	CHARLOTTE
State	:	NC
Zip	:	28226
Country	:	US
Telephone Number	:	336-425-5991
Fax Number	:

Provider Business Practice Location Address
First Line	:	8000 WATERFORD TIDE LOOP
Second Line	:	#2931
City	:	CHARLOTTE
State	:	NC
Zip	:	28226
Country	:	US
Telephone Number	:	336-425-5991
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/21/2011
Last Update Date	:	07/21/2011

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