Healthcare Provider Details

I. General information

NPI: 1851681183
Provider Name (Legal Business Name): SURGERY CLINIC, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/07/2011
Last Update Date: 08/17/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

395 NORTHWOOD DR
CENTRE AL
35960-1045
US

IV. Provider business mailing address

419 S 5TH ST
GADSDEN AL
35901-5101
US

V. Phone/Fax

Practice location:
  • Phone: 256-547-6331
  • Fax: 256-547-1711
Mailing address:
  • Phone: 256-547-6331
  • Fax: 256-547-1711

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: MRS. DIANETTE KEENER
Title or Position: BILLING MANAGER
Credential:
Phone: 256-547-6331