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General NPI Number Information
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NPI Number | 1538166012
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Entity Type | Organization
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Legal Business Name | CLAYTON OUTPATIENT SURGICAL CENTER
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Dates
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Enumeration Date | 06/30/2005
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Last Update Date | 08/12/2010
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Provider Practice Location Address
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Address Line | 6911 TARA BLVD SUITE 104
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City | JONESBORO
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State | GA
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Zip | 30236-1503
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Country | US
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Telephone | 770-477-9535
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Fax | 770-471-7826
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Provider Business Mailing Address
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Address Line | 6911 TARA BLVD SUITE 104
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City | JONESBORO
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State | GA
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Zip | 30236-1503
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Country | US
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Telephone | 770-477-9535
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Fax | 770-471-7826
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Authorized Official
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Title or Position | MEDICAL DIRECTOR
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Name | DR. STANLEY KALISH
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Credential | DPM
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Telephone | 770-477-9535
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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 | 031-070
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License Number State | GA
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