1538609367 NPI number — PERIOP SURGICAL ALLIANCE SOUTHWEST LLC

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 1538609367 NPI number — PERIOP SURGICAL ALLIANCE SOUTHWEST LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PERIOP SURGICAL ALLIANCE SOUTHWEST LLC
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:
PERIOP SURGICAL ALLIANCE SOUTHWEST LLC
Provider Other Organization Name Type Code:
3
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:
1538609367
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/09/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2300 WOODFOREST PKWY N STE 250-162
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MONTGOMERY
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
77316-6501
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
936-760-6591
Provider Business Mailing Address Fax Number:
936-582-6013

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
17200 ST LUKES WAY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
THE WOODLANDS
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77384-8007
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
936-760-6591
Provider Business Practice Location Address Fax Number:
936-582-6013
Provider Enumeration Date:
02/27/2017

Additional Information

Authorized Official

Authorized Official Last Name:
YARRITO
Authorized Official First Name:
ELIAS
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
936-760-6591

Provider Taxonomy Codes

  • Taxonomy code: 208600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 246ZC0007X , with the licence number: SA00395 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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





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