=====================================================
General NPI Number Information
=====================================================
NPI Number | 1255700092
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SPECIFIED SOLUTIONS SURGICAL ASSOCIATES, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/23/2015
-----------------------------------------------------
Last Update Date | 12/05/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 156 FOSTER DR STE A
-----------------------------------------------------
City | MCDONOUGH
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30253-5346
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-932-0295
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 207 ARABELLA PKWY
-----------------------------------------------------
City | LOCUST GROVE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30248-4250
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-932-0295
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | JERROD LAQUINTON WILLIAMS SR.
-----------------------------------------------------
Credential | CSA
-----------------------------------------------------
Telephone | 404-932-0295
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363AS0400X
-----------------------------------------------------
Taxonomy Name | Surgical Physician Assistant
-----------------------------------------------------
License Number | 2610
-----------------------------------------------------
License Number State | DC
-----------------------------------------------------