MEDICARE: OLYMPIAN SURGICAL ASSISTANTS

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	208600000X	Surgery Physician	051517853	GA
2	363AS0400X	Surgical Physician Assistant

General Provider Information

NPI Number	:	1366978991
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OLYMPIAN SURGICAL ASSISTANTS

Provider Business Mailing Address
First Line	:	PO BOX 81
Second Line	:
City	:	MARIETTA
State	:	GA
Zip	:	30061-0081
Country	:	US
Telephone Number	:	678-517-3428
Fax Number	:	770-485-1534

Provider Business Practice Location Address
First Line	:	55 ATLANTA ST SE STE 204
Second Line	:
City	:	MARIETTA
State	:	GA
Zip	:	30060-1977
Country	:	US
Telephone Number	:	678-517-3428
Fax Number	:	770-485-1534

Authorized Official
Title or Position	:	OWNER/DIRECTOR
Name	:	BRANDON VIRDELL KING
Credential	:
Telephone Number	:	678-517-3428

Provider Enumeration Date	:	05/02/2017
Last Update Date	:	11/24/2021

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