Basic Information
| Provider Information | |||||||||
| NPI: | 1164501862 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SURGICAL ASSOCIATES OF MARTIN PC | ||||||||
| LastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 300 W PEACH ST | ||||||||
| Address2: | |||||||||
| City: | MARTIN | ||||||||
| State: | TN | ||||||||
| PostalCode: | 382373949 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7315872525 | ||||||||
| FaxNumber: | 7315872555 | ||||||||
| Practice Location | |||||||||
| Address1: | 300 W PEACH ST | ||||||||
| Address2: | |||||||||
| City: | MARTIN | ||||||||
| State: | TN | ||||||||
| PostalCode: | 382373949 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7315872525 | ||||||||
| FaxNumber: | 7315872555 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/03/2006 | ||||||||
| LastUpdateDate: | 10/29/2008 | ||||||||
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| AuthorizedOfficialLastName: | DUNCAN | ||||||||
| AuthorizedOfficialFirstName: | PATSY | ||||||||
| AuthorizedOfficialMiddleName: | G | ||||||||
| AuthorizedOfficialTitleorPosition: | OFFICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 7315872525 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | Y | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 3725673 | 05 | TN | MEDICAID |