Basic Information
| Provider Information | |||||||||
| NPI: | 1740312040 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PEACH STATE SURGICAL CENTERS, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 6007 | ||||||||
| Address2: | |||||||||
| City: | WARNER ROBINS | ||||||||
| State: | GA | ||||||||
| PostalCode: | 310956007 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4789290036 | ||||||||
| FaxNumber: | 4789291744 | ||||||||
| Practice Location | |||||||||
| Address1: | 1040 MORNINGSIDE DR | ||||||||
| Address2: | |||||||||
| City: | PERRY | ||||||||
| State: | GA | ||||||||
| PostalCode: | 310692904 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4789884676 | ||||||||
| FaxNumber: | 4789877907 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/12/2007 | ||||||||
| LastUpdateDate: | 02/22/2008 | ||||||||
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| AuthorizedOfficialLastName: | JOKHAI | ||||||||
| AuthorizedOfficialFirstName: | SARVEPALLI | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 4784751299 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | DPM | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213E00000X | POD000829 | GA | Y | 193400000X SINGLE SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist |
No ID Information.