Healthcare Provider Details

I. General information

NPI: 1790043453
Provider Name (Legal Business Name): PREFERRED SURGICAL ASSOCIATES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/01/2012
Last Update Date: 06/29/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1610 TAZEWELL RD STE 301
TAZEWELL TN
37879-3600
US

IV. Provider business mailing address

PO BOX 1349
NEW TAXWELL TN
37825-1349
US

V. Phone/Fax

Practice location:
  • Phone: 423-626-4288
  • Fax: 423-626-1101
Mailing address:
  • Phone: 865-670-6199
  • Fax: 865-670-6188

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number StateTN

VIII. Authorized Official

Name: ROBERT J. WILMOTH
Title or Position: SOLE OWNER
Credential: MD
Phone: 423-626-4288