Provider Demographics
NPI:1538166012
Name:CLAYTON OUTPATIENT SURGICAL CENTER
Entity type:Organization
Organization Name:CLAYTON OUTPATIENT SURGICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:STANLEY
Authorized Official - Middle Name:
Authorized Official - Last Name:KALISH
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:770-477-9535
Mailing Address - Street 1:6911 TARA BLVD
Mailing Address - Street 2:SUITE 104
Mailing Address - City:JONESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30236-1503
Mailing Address - Country:US
Mailing Address - Phone:770-477-9535
Mailing Address - Fax:770-471-7826
Practice Address - Street 1:6911 TARA BLVD
Practice Address - Street 2:SUITE 104
Practice Address - City:JONESBORO
Practice Address - State:GA
Practice Address - Zip Code:30236-1503
Practice Address - Country:US
Practice Address - Phone:770-477-9535
Practice Address - Fax:770-471-7826
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-30
Last Update Date:2010-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA031-070261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00649833AMedicaid
GA490002632OtherRAILROAD MEDICARE
GA111048ASCAMedicare ID - Type Unspecified