MEDICARE: SURGICAL SYNERGY, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant

General Provider Information

NPI Number	:	1124489968
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SURGICAL SYNERGY, LLC

Provider Business Mailing Address
First Line	:	1265 E FORT UNION BLVD STE 120
Second Line	:
City	:	COTTONWOOD HEIGHTS
State	:	UT
Zip	:	84047-1845
Country	:	US
Telephone Number	:	801-917-5561
Fax Number	:

Provider Business Practice Location Address
First Line	:	1265 E FORT UNION BLVD STE 120
Second Line	:
City	:	COTTONWOOD HEIGHTS
State	:	UT
Zip	:	84047-1845
Country	:	US
Telephone Number	:	801-917-5561
Fax Number	:	801-572-9992

Authorized Official
Title or Position	:	MANAGER
Name	:	STEPHANIE BOULTER
Credential	:	PA-C
Telephone Number	:	801-995-1235

Provider Enumeration Date	:	03/07/2016
Last Update Date	:	07/08/2025

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