MEDICARE: MAINESTATE SURGICAL SERVICES, 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	163WR0006X	Registered Nurse First Assistant	16052680	GA

General Provider Information

NPI Number	:	1366892952
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MAINESTATE SURGICAL SERVICES, LLC

Provider Business Mailing Address
First Line	:	1720 SHIRE VILLAGE DR
Second Line	:
City	:	SUGAR HILL
State	:	GA
Zip	:	30518-2922
Country	:	US
Telephone Number	:	678-332-8596
Fax Number	:

Provider Business Practice Location Address
First Line	:	1720 SHIRE VILLAGE DR
Second Line	:
City	:	SUGAR HILL
State	:	GA
Zip	:	30518-2922
Country	:	US
Telephone Number	:	678-332-8596
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	MR. VERNON GEORGE ROUZEAU-SAUNDERS
Credential	:	RN, RNFA
Telephone Number	:	678-332-8596

Provider Enumeration Date	:	06/15/2016
Last Update Date	:	06/15/2016

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