Basic Information
| Provider Information | |||||||||
| NPI: | 1760518112 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SURGICAL ASSOCIATES OF MEDINA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 970 E WASHINGTON ST | ||||||||
| Address2: | SUITE 6-C | ||||||||
| City: | MEDINA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 442563332 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3307223083 | ||||||||
| FaxNumber: | 3307255043 | ||||||||
| Practice Location | |||||||||
| Address1: | 3724 CENTER RD | ||||||||
| Address2: | SUITE 103 | ||||||||
| City: | BRUNSWICK | ||||||||
| State: | OH | ||||||||
| PostalCode: | 442124400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3302734443 | ||||||||
| FaxNumber: | 3302734443 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/27/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | BICA | ||||||||
| AuthorizedOfficialFirstName: | THOMAS | ||||||||
| AuthorizedOfficialMiddleName: | DENNIS | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3307223083 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 246ZS0410X | Y | 193400000X SINGLE SPECIALTY GROUP |
ID Information
| ID | Type | State | Issuer | Description | 0723168 | 05 | OH | MEDICAID |