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General NPI Number Information
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NPI Number | 1982069068
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Entity Type | Organization
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Legal Business Name | RAIDER SURGICAL CENTER LLC
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Dates
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Enumeration Date | 12/16/2015
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Last Update Date | 03/10/2017
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Provider Practice Location Address
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Address Line | 1400 E RIDGE RD STE 3
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City | MCALLEN
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State | TX
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Zip | 78503-1536
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Country | US
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Telephone | 956-429-4900
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Fax | 956-429-4901
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Provider Business Mailing Address
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Address Line | 1519 E 6TH ST
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City | WESLACO
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State | TX
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Zip | 78596-6605
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Country | US
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Telephone | 956-429-4900
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Fax | 956-429-4901
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Authorized Official
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Title or Position | OWNER
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Name | DR. WADE A GRAHAM
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Credential | MD
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Telephone | 956-429-4900
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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 | 130305
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License Number State | TX
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