MEDICARE: PPG SPECIAL PROCEDURES, LLC

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	261QA1903X	Ambulatory Surgical Clinic/Center

General Provider Information

NPI Number	:	1407557556
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PPG SPECIAL PROCEDURES, LLC

Provider Business Mailing Address
First Line	:	1000 W CANNON ST
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76104-3029
Country	:	US
Telephone Number	:	817-725-7990
Fax Number	:

Provider Business Practice Location Address
First Line	:	500 LIPSCOMB ST
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76104-2239
Country	:	US
Telephone Number	:	817-870-2616
Fax Number	:

Authorized Official
Title or Position	:	SOLE MEMBER
Name	:	DR. SARAVANAN BALAMUTHUSAMY
Credential	:	MD
Telephone Number	:	817-870-2616

Provider Enumeration Date	:	03/15/2023
Last Update Date	:	05/03/2023

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