Healthcare Provider Details

I. General information

NPI: 1538166012
Provider Name (Legal Business Name): CLAYTON OUTPATIENT SURGICAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/30/2005
Last Update Date: 08/12/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6911 TARA BLVD SUITE 104
JONESBORO GA
30236-1503
US

IV. Provider business mailing address

6911 TARA BLVD SUITE 104
JONESBORO GA
30236-1503
US

V. Phone/Fax

Practice location:
  • Phone: 770-477-9535
  • Fax: 770-471-7826
Mailing address:
  • Phone: 770-477-9535
  • Fax: 770-471-7826

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number031-070
License Number StateGA

VIII. Authorized Official

Name: DR. STANLEY KALISH
Title or Position: MEDICAL DIRECTOR
Credential: DPM
Phone: 770-477-9535