Basic Information
| Provider Information | |||||||||
| NPI: | 1295762540 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SURGICAL CLINIC PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 121 N 20TH ST | ||||||||
| Address2: | BLDG 3 | ||||||||
| City: | OPELIKA | ||||||||
| State: | AL | ||||||||
| PostalCode: | 368015449 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3347456271 | ||||||||
| FaxNumber: | 3347429879 | ||||||||
| Practice Location | |||||||||
| Address1: | 121 N 20TH ST | ||||||||
| Address2: | BLDG 3 | ||||||||
| City: | OPELIKA | ||||||||
| State: | AL | ||||||||
| PostalCode: | 368015449 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3347456271 | ||||||||
| FaxNumber: | 3347429879 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/26/2006 | ||||||||
| LastUpdateDate: | 05/07/2010 | ||||||||
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| AuthorizedOfficialLastName: | THOMAS | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | S | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3347456271 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X | 00012101 | AL | Y | Ambulatory Health Care Facilities | Clinic/Center |
ID Information
| ID | Type | State | Issuer | Description | 529402890 | 05 | AL | MEDICAID |