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General NPI Number Information
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NPI Number | 1942573381
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Entity Type | Organization
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Legal Business Name | GOOD SHEPHERD SURGICAL ASSOCIATES, PLLC
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Dates
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Enumeration Date | 02/15/2012
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Last Update Date | 04/13/2015
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Provider Practice Location Address
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Address Line | 703 E MARSHALL AVE SUITE 3000
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City | LONGVIEW
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State | TX
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Zip | 75601-5500
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Country | US
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Telephone | 903-315-4400
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Fax | 903-315-2595
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Provider Business Mailing Address
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Address Line | PO BOX 4207
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City | LONGVIEW
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State | TX
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Zip | 75606-4207
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Country | US
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Telephone | 903-315-4400
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Fax | 903-315-2595
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Authorized Official
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Title or Position | EVP/COO
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Name | KRISTINE GLOVER
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Credential |
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Telephone | 903-315-5704
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208600000X
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Taxonomy Name | Surgery Physician
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License Number |
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License Number State |
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