Basic Information
| Provider Information | |||||||||
| NPI: | 1750449443 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PREMIER SURGICAL ASSOCIATES, PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 52948 | ||||||||
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| City: | KNOXVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 379502948 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8653065675 | ||||||||
| FaxNumber: | 8655847712 | ||||||||
| Practice Location | |||||||||
| Address1: | 6408 PAPERMILL DR | ||||||||
| Address2: | SUITE 220 | ||||||||
| City: | KNOXVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 379194858 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8653065675 | ||||||||
| FaxNumber: | 8655847712 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/05/2006 | ||||||||
| LastUpdateDate: | 08/07/2019 | ||||||||
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| AuthorizedOfficialLastName: | BURRIS | ||||||||
| AuthorizedOfficialFirstName: | GARY | ||||||||
| AuthorizedOfficialMiddleName: | KEVIN | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 8653065675 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2086S0129X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | Vascular Surgery | 2086X0206X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | Surgical Oncology | 208C00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Colon & Rectal Surgery | 208600000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 3707870 | 05 | TN | MEDICAID |