MEDICARE: SURGERY CLINIC, 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	208600000X	Surgery Physician		AL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1780068460
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SURGERY CLINIC, LLC

Provider Business Mailing Address
First Line	:	419 S 5TH ST
Second Line	:
City	:	GADSDEN
State	:	AL
Zip	:	35901-5101
Country	:	US
Telephone Number	:	256-547-6331
Fax Number	:	256-547-1711

Provider Business Practice Location Address
First Line	:	1622 CHURCH AVE SE
Second Line	:
City	:	JACKSONVILLE
State	:	AL
Zip	:	36265-3200
Country	:	US
Telephone Number	:	256-547-6331
Fax Number	:	256-547-1711

Authorized Official
Title or Position	:	BILLING MANAGER
Name	:	MRS. DIANETTE KEENER
Credential	:
Telephone Number	:	256-547-6331

Provider Enumeration Date	:	07/13/2015
Last Update Date	:	02/10/2021

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Directions to “SURGERY CLINIC, LLC ” Practice Location

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