MEDICARE: MILLENNIUM SURGICAL ASSOCIATES STAFFING, 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	363AS0400X	Surgical Physician Assistant		TX
2	246ZC0007X	Surgical Assistant	SA00475	TX

General Provider Information

NPI Number	:	1588095111
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MILLENNIUM SURGICAL ASSOCIATES STAFFING, LLC

Provider Business Mailing Address
First Line	:	2437 BAY AREA BLVD
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77058-1519
Country	:	US
Telephone Number	:	832-891-9989
Fax Number	:	866-576-4221

Provider Business Practice Location Address
First Line	:	2437 BAY AREA BLVD
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77058-1519
Country	:	US
Telephone Number	:	832-891-9989
Fax Number	:	866-576-4221

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	MS. THERESA MARIE HESLOP
Credential	:	LSA, CSA
Telephone Number	:	832-891-9989

Provider Enumeration Date	:	12/08/2013
Last Update Date	:	04/11/2016

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