Basic Information
| Provider Information | |||||||||
| NPI: | 1538119631 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ASSOCIATES IN SURGERY PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1880 | ||||||||
| Address2: | |||||||||
| City: | CONWAY | ||||||||
| State: | SC | ||||||||
| PostalCode: | 295281880 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8433477291 | ||||||||
| FaxNumber: | 8433470139 | ||||||||
| Practice Location | |||||||||
| Address1: | 2361 CYPRESS CIR | ||||||||
| Address2: | |||||||||
| City: | CONWAY | ||||||||
| State: | SC | ||||||||
| PostalCode: | 295268921 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8433477291 | ||||||||
| FaxNumber: | 8433470139 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/11/2006 | ||||||||
| LastUpdateDate: | 12/31/2013 | ||||||||
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| AuthorizedOfficialLastName: | ELLIS | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | H | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8433497090 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | PC4964 | 05 | SC | MEDICAID |