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General NPI Number Information
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NPI Number | 1063498657
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Entity Type | Organization
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Legal Business Name | NORTHEAST TEXAS SURGERY CENTER
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Dates
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Enumeration Date | 12/16/2005
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Last Update Date | 08/12/2008
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Provider Practice Location Address
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Address Line | 1902 MOORES LN SUITE B
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City | TEXARKANA
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State | TX
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Zip | 75503-4610
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Country | US
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Telephone | 903-792-2108
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Fax | 903-792-0606
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Provider Business Mailing Address
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Address Line | 1902 MOORES LN SUITE B
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City | TEXARKANA
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State | TX
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Zip | 75503-4610
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Country | US
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Telephone | 903-792-2108
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Fax | 903-792-0606
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Authorized Official
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Title or Position | ASC DIRECTOR
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Name | MS. PENNY JO BURNHAM
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Credential | RN
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Telephone | 903-792-2108
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QA1903X
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Taxonomy Name | Ambulatory Surgical Clinic/Center
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License Number | 008109
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License Number State | TX
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Taxonomy #2
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Taxonomy Code | 261QA1903X
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Taxonomy Name | Ambulatory Surgical Clinic/Center
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License Number | 008678
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License Number State | TX
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