MEDICARE: GLENEAGLES SURGERY CENTER, 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	261QA1903X	Ambulatory Surgical Clinic/Center

General Provider Information

NPI Number	:	1255000329
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GLENEAGLES SURGERY CENTER, LLC

Provider Business Mailing Address
First Line	:	2633 DALLAS PKWY STE 100
Second Line	:
City	:	PLANO
State	:	TX
Zip	:	75093-4715
Country	:	US
Telephone Number	:	972-403-7733
Fax Number	:	972-403-7744

Provider Business Practice Location Address
First Line	:	2633 DALLAS PKWY STE 100
Second Line	:
City	:	PLANO
State	:	TX
Zip	:	75093-4715
Country	:	US
Telephone Number	:	972-403-7733
Fax Number	:	972-403-7744

Authorized Official
Title or Position	:	DPM
Name	:	JEREMIAH A GRAFF
Credential	:	MD
Telephone Number	:	142-205-1078

Provider Enumeration Date	:	09/10/2021
Last Update Date	:	09/10/2021

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