Healthcare Provider Details

I. General information

NPI: 1871192377
Provider Name (Legal Business Name): SURGERY MANAGEMENT GROUP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/26/2020
Last Update Date: 10/26/2020
Certification Date: 10/26/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1808 E AZTEC AVE STE 2
GALLUP NM
87301-4946
US

IV. Provider business mailing address

1200 E COLLINS BLVD
RICHARDSON TX
75081-2457
US

V. Phone/Fax

Practice location:
  • Phone: 469-235-5588
  • Fax: 866-600-7772
Mailing address:
  • Phone: 469-235-5588
  • Fax: 866-600-7772

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State

VIII. Authorized Official

Name: TERRENCE JOHNSON
Title or Position: OWNER
Credential:
Phone: 469-235-5588