Healthcare Provider Details

I. General information

NPI: 1427196476
Provider Name (Legal Business Name): CERTIFIED SURGEONS, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/02/2007
Last Update Date: 09/28/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 S BROADWAY
PERU IN
46970-2231
US

IV. Provider business mailing address

1 S BROADWAY
PERU IN
46970-2231
US

V. Phone/Fax

Practice location:
  • Phone: 765-472-7700
  • Fax: 765-472-7700
Mailing address:
  • Phone: 765-472-7700
  • Fax: 765-472-7700

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number01031765A
License Number StateIN

VIII. Authorized Official

Name: TRISTAN VAUN STONGER
Title or Position: OWNER
Credential: M.D.
Phone: 765-472-7700