Provider Demographics
NPI:1003980541
Name:SOUTH BRANCH SURGICAL ASSOCIATES INC
Entity Type:Organization
Organization Name:SOUTH BRANCH SURGICAL ASSOCIATES INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ANIL
Authorized Official - Middle Name:K
Authorized Official - Last Name:MAKANI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:304-257-4331
Mailing Address - Street 1:PO BOX 788
Mailing Address - Street 2:
Mailing Address - City:PETERSBURG
Mailing Address - State:WV
Mailing Address - Zip Code:26847-0788
Mailing Address - Country:US
Mailing Address - Phone:304-257-4331
Mailing Address - Fax:304-257-2891
Practice Address - Street 1:GRANT MEMORIAL HOSPITAL
Practice Address - Street 2:ROUTE 55
Practice Address - City:PETERSBURG
Practice Address - State:WV
Practice Address - Zip Code:26847-0788
Practice Address - Country:US
Practice Address - Phone:304-257-4331
Practice Address - Fax:304-257-2891
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-17
Last Update Date:2008-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV15545208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0009932000Medicaid
9270681Medicare ID - Type Unspecified