Basic Information
| Provider Information | |||||||||
| NPI: | 1821048448 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ADVANCED SURGICAL ASSOCIATES | ||||||||
| LastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 2376 CYPRESS CIR | ||||||||
| Address2: | SUITE 103 | ||||||||
| City: | CONWAY | ||||||||
| State: | SC | ||||||||
| PostalCode: | 295268964 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8433473900 | ||||||||
| FaxNumber: | 8433473930 | ||||||||
| Practice Location | |||||||||
| Address1: | 2376 CYPRESS CIR | ||||||||
| Address2: | SUITE 103 | ||||||||
| City: | CONWAY | ||||||||
| State: | SC | ||||||||
| PostalCode: | 295268964 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8433473900 | ||||||||
| FaxNumber: | 8433473930 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/12/2006 | ||||||||
| LastUpdateDate: | 10/22/2007 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BALDER | ||||||||
| AuthorizedOfficialFirstName: | DONALD | ||||||||
| AuthorizedOfficialMiddleName: | ALLAN | ||||||||
| AuthorizedOfficialTitleorPosition: | PARTNER | ||||||||
| AuthorizedOfficialTelephone: | 8433473900 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
No ID Information.