Healthcare Provider Details

I. General information

NPI: 1013341171
Provider Name (Legal Business Name): SURGICAL SUPPORT SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/26/2013
Last Update Date: 08/26/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12439 WALNUT HILL DRIVE
ROCKVILLE VA
23146
US

IV. Provider business mailing address

P.O BOX 99
ROCKVILLE VA
23146
US

V. Phone/Fax

Practice location:
  • Phone: 804-749-4249
  • Fax:
Mailing address:
  • Phone: 804-749-4249
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2086X0206X
TaxonomySurgical Oncology Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State

VIII. Authorized Official

Name: PRESCOTT WADE PRILLAMAN
Title or Position: PRESIDENT
Credential: MD
Phone: 804-683-5849