Basic Information
Provider Information | |||||||||
NPI: | 1871832949 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | PROFESSIONAL SURGICAL ASSISTING SERVICES | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 116 BRITTANY LN | ||||||||
Address2: |   | ||||||||
City: | GLASGOW | ||||||||
State: | KY | ||||||||
PostalCode: | 421415120 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2702029006 | ||||||||
FaxNumber: | 8004974153 | ||||||||
Practice Location | |||||||||
Address1: | 1301 N RACE ST | ||||||||
Address2: |   | ||||||||
City: | GLASGOW | ||||||||
State: | KY | ||||||||
PostalCode: | 421413454 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2706514444 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/08/2013 | ||||||||
LastUpdateDate: | 02/08/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | MINTON | ||||||||
AuthorizedOfficialFirstName: | BILLY | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 2702029006 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | SA-C, KCSA | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 246ZS0410X | 0626254 | KY | Y | 193200000X MULTI-SPECIALTY GROUP |   |   |   |
No ID Information.