1316959612 NPI number — SURGICAL ASSOCIATES OF SMYTH COUNTY, PC

Table of content: (NPI 1316959612)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1316959612 NPI number — SURGICAL ASSOCIATES OF SMYTH COUNTY, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SURGICAL ASSOCIATES OF SMYTH COUNTY, PC
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:
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:
1316959612
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/01/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1203 SNIDER ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MARION
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
24354-4221
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
276-782-9113
Provider Business Mailing Address Fax Number:
276-782-9833

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1203 SNIDER ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MARION
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
24354-4221
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
276-782-9113
Provider Business Practice Location Address Fax Number:
276-782-9833
Provider Enumeration Date:
08/13/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BAUMAN
Authorized Official First Name:
LYLE
Authorized Official Middle Name:
W
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
276-782-9113

Provider Taxonomy Codes

  • Taxonomy code: 208600000X , with the licence number:  0101049504 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 7367899 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 282451 . This is a "ANTHEM" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".




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