MEDICARE: THE SURGERY CENTER OF GEORGIA, 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		GA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1282933	OTHER	GA	UNITED HEALTHCARE
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1336143171
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	THE SURGERY CENTER OF GEORGIA, LLC

Provider Business Mailing Address
First Line	:	220 HOSPITAL RD
Second Line	:
City	:	CANTON
State	:	GA
Zip	:	30114-2407
Country	:	US
Telephone Number	:	770-479-2202
Fax Number	:	770-479-3891

Provider Business Practice Location Address
First Line	:	220 HOSPITAL RD
Second Line	:
City	:	CANTON
State	:	GA
Zip	:	30114-2407
Country	:	US
Telephone Number	:	770-479-2202
Fax Number	:	770-479-3891

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	MS. JUDITH GRADY
Credential	:	R.N.
Telephone Number	:	770-479-2202

Provider Enumeration Date	:	06/09/2005
Last Update Date	:	07/14/2008

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