MEDICARE: JAMES ROY SANDERSON SURGICAL ASSTANT

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

General Provider Information

NPI Number	:	1164999009
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JAMES ROY SANDERSON SURGICAL ASSTANT

Provider Business Mailing Address
First Line	:	223 MYRTLE ST W
Second Line	:
City	:	PHILADELPHIA
State	:	MS
Zip	:	39350-3037
Country	:	US
Telephone Number	:	601-562-4669
Fax Number	:

Provider Business Practice Location Address
First Line	:	223 MYRTLE ST W
Second Line	:
City	:	PHILADELPHIA
State	:	MS
Zip	:	39350-3037
Country	:	US
Telephone Number	:	601-562-4669
Fax Number	:

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

Provider Enumeration Date	:	10/29/2018
Last Update Date	:	10/29/2018

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