MEDICARE: PREFERRED SURGICAL ASSOCIATES

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	208600000X	Surgery Physician		TN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1790043453
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PREFERRED SURGICAL ASSOCIATES

Provider Business Mailing Address
First Line	:	PO BOX 1349
Second Line	:
City	:	NEW TAXWELL
State	:	TN
Zip	:	37825-1349
Country	:	US
Telephone Number	:	865-670-6199
Fax Number	:	865-670-6188

Provider Business Practice Location Address
First Line	:	1610 TAZEWELL RD
Second Line	:	STE 301
City	:	TAZEWELL
State	:	TN
Zip	:	37879-3600
Country	:	US
Telephone Number	:	423-626-4288
Fax Number	:	423-626-1101

Authorized Official
Title or Position	:	SOLE OWNER
Name	:	ROBERT J. WILMOTH
Credential	:	MD
Telephone Number	:	423-626-4288

Provider Enumeration Date	:	05/01/2012
Last Update Date	:	06/29/2012

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Directions to “PREFERRED SURGICAL ASSOCIATES ” Practice Location

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