=====================================================
General NPI Number Information
=====================================================
NPI Number | 1639653678
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PRIORITY SURGICAL CARE, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/15/2018
-----------------------------------------------------
Last Update Date | 09/15/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3050 S CENTER ST STE 160
-----------------------------------------------------
City | ARLINGTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76014-2155
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 214-886-2108
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3050 S CENTER ST STE 160
-----------------------------------------------------
City | ARLINGTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76014-2155
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 214-886-2108
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. JEFFREY WASSERMAN
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 214-886-2108
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QH0100X
-----------------------------------------------------
Taxonomy Name | Health Service Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------