1205440054 NPI number — PHYSICIAN ASSISTANT SURGICAL SOLUTIONS

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205440054 NPI number — PHYSICIAN ASSISTANT SURGICAL SOLUTIONS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PHYSICIAN ASSISTANT SURGICAL SOLUTIONS
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:
1205440054
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/31/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4290 BELLS FERRY ROAD
Provider Second Line Business Mailing Address:
SUITE 134 - 1032
Provider Business Mailing Address City Name:
KENNESAW
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30144
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
770-325-0836
Provider Business Mailing Address Fax Number:
770-670-4764

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4290 BELLS FERRY ROAD
Provider Second Line Business Practice Location Address:
SUITE 134 - 1032
Provider Business Practice Location Address City Name:
KENNESAW
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30144
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
770-325-0836
Provider Business Practice Location Address Fax Number:
770-670-4764
Provider Enumeration Date:
08/31/2020

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
PARKS
Authorized Official First Name:
LINDSEY
Authorized Official Middle Name:
NICOLE
Authorized Official Title or Position:
OWNER/CEO
Authorized Official Telephone Number:
770-325-0836

Provider Taxonomy Codes

  • Taxonomy code: 208600000X , registered in the state of NULL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363AS0400X , registered in the state of NULL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 246ZC0007X , registered in the state of NULL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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