Basic Information
| Provider Information | |||||||||
| NPI: | 1790715506 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTHERN SURGICAL ASSOCIATES LLC | ||||||||
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| OtherOrganizationName: | COMMONWEALTH SURGICAL ASSOCIATES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3640 HIGH ST | ||||||||
| Address2: | SUITE 2F | ||||||||
| City: | PORTSMOUTH | ||||||||
| State: | VA | ||||||||
| PostalCode: | 237073213 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7573972383 | ||||||||
| FaxNumber: | 7573975201 | ||||||||
| Practice Location | |||||||||
| Address1: | 3640 HIGH ST | ||||||||
| Address2: | SUITE 2F | ||||||||
| City: | PORTSMOUTH | ||||||||
| State: | VA | ||||||||
| PostalCode: | 237073213 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7573972383 | ||||||||
| FaxNumber: | 7573975201 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/04/2006 | ||||||||
| LastUpdateDate: | 01/14/2008 | ||||||||
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| AuthorizedOfficialLastName: | TENEKJIAN | ||||||||
| AuthorizedOfficialFirstName: | VASKEN | ||||||||
| AuthorizedOfficialMiddleName: | KEVORK | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7573972383 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | 208G00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Thoracic Surgery (Cardiothoracic Vascular Surgery) | 2086S0129X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | Vascular Surgery |
ID Information
| ID | Type | State | Issuer | Description | C05853 | 01 | VA | MEDICARE GROUP NUMBER | OTHER |