Healthcare Provider Details

I. General information

NPI: 1245623735
Provider Name (Legal Business Name): SURGICAL SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/09/2015
Last Update Date: 03/09/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4084 AUDUBON DR
MARIETTA GA
30068-2605
US

IV. Provider business mailing address

4084 AUDUBON DR
MARIETTA GA
30068-2605
US

V. Phone/Fax

Practice location:
  • Phone: 770-985-4257
  • Fax: 770-985-4258
Mailing address:
  • Phone: 770-985-4257
  • Fax: 770-985-4258

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246ZC0007X
TaxonomySurgical Assistant
License Number1614
License Number StateGA

VIII. Authorized Official

Name: PAM PHILLIP
Title or Position: PATIENT ACCOUNT MANAGER
Credential:
Phone: 770-985-4257