Provider Demographics
NPI:1861568040
Name:SURGICAL SPECIALISTS OF GEORGIA, PC
Entity type:Organization
Organization Name:SURGICAL SPECIALISTS OF GEORGIA, PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:BUSINESS OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:AMY
Authorized Official - Middle Name:D
Authorized Official - Last Name:SEABOLT
Authorized Official - Suffix:
Authorized Official - Credentials:BSBA
Authorized Official - Phone:770-534-0110
Mailing Address - Street 1:1250 JESSE JEWELL PKWY SE
Mailing Address - Street 2:SUITE 300
Mailing Address - City:GAINESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30501-3871
Mailing Address - Country:US
Mailing Address - Phone:770-534-0110
Mailing Address - Fax:770-534-2555
Practice Address - Street 1:1250 JESSE JEWELL PKWY SE
Practice Address - Street 2:SUITE 300
Practice Address - City:GAINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30501-3871
Practice Address - Country:US
Practice Address - Phone:770-534-0110
Practice Address - Fax:770-534-2555
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-28
Last Update Date:2009-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA050992208600000X
GA059108208600000X
GARN171688NP363L00000X
GA0357362086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Multi-Specialty
No208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGRP4287Medicare ID - Type UnspecifiedMEDICARE GROUP #