Basic Information
| Provider Information | |||||||||
| NPI: | 1780650465 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SURGICAL SPECIALISTS, P.C. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 252 | ||||||||
| Address2: | |||||||||
| City: | BRYN MAWR | ||||||||
| State: | PA | ||||||||
| PostalCode: | 190100252 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 11 INDUSTRIAL BLVD | ||||||||
| Address2: | PAOLI POINTE STE 102 | ||||||||
| City: | PAOLI | ||||||||
| State: | PA | ||||||||
| PostalCode: | 193011632 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6106473077 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/23/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | MATTSON | ||||||||
| AuthorizedOfficialFirstName: | RONALD | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT OF CORPORATION | ||||||||
| AuthorizedOfficialTelephone: | 6105271185 | ||||||||
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| 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 | 2086S0129X | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | Vascular Surgery | 208600000X | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 0017456690001 | 05 | PA | MEDICAID |