=====================================================
General NPI Number Information
=====================================================
NPI Number | 1376973420
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SUFFOLK SURGICAL ASSOCIATES LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/26/2013
-----------------------------------------------------
Last Update Date | 03/21/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2000 MEADE PKWY
-----------------------------------------------------
City | SUFFOLK
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23434-4259
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-539-0251
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2000 MEADE PKWY
-----------------------------------------------------
City | SUFFOLK
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23434-4259
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-539-0251
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | PAUL HOGG
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 757-539-0251
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208600000X
-----------------------------------------------------
Taxonomy Name | Surgery Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------