Provider Demographics
NPI:1033190129
Name:MAE PHYSICIANS SURGERY CENTER, LLC
Entity type:Organization
Organization Name:MAE PHYSICIANS SURGERY CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:CARLA
Authorized Official - Middle Name:
Authorized Official - Last Name:GLAZE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-968-1790
Mailing Address - Street 1:PO BOX 12673
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39236-2673
Mailing Address - Country:US
Mailing Address - Phone:601-968-1790
Mailing Address - Fax:601-292-4531
Practice Address - Street 1:1190 N STATE ST
Practice Address - Street 2:STE 102
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39202-2413
Practice Address - Country:US
Practice Address - Phone:601-968-1790
Practice Address - Fax:601-292-4531
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-07
Last Update Date:2014-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical