1033223748 NPI number — PHYSICIANS SURGERY CENTER OF WACO

Table of content: (NPI 1033223748)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1033223748 NPI number — PHYSICIANS SURGERY CENTER OF WACO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PHYSICIANS SURGERY CENTER OF WACO
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1033223748
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/19/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3323 S LOOP 256
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PALESTINE
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75801-6977
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
903-723-1010
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2201 W LOOP 340
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WACO
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76712-6856
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
254-772-6200
Provider Business Practice Location Address Fax Number:
254-420-3057
Provider Enumeration Date:
08/18/2006

Additional Information

Authorized Official

Authorized Official Last Name:
SHILLER
Authorized Official First Name:
ALAN
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
903-723-1010

Provider Taxonomy Codes

  • Taxonomy code: 261QA1903X , with the licence number:  008275 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 181299201 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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