Provider Demographics
NPI:1043361645
Name:SURGICAL SPECIALTIES, PSC.
Entity Type:Organization
Organization Name:SURGICAL SPECIALTIES, PSC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TRACY
Authorized Official - Middle Name:GLENN
Authorized Official - Last Name:CROSS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:606-387-3000
Mailing Address - Street 1:250 BURKESVILLE RD
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:KY
Mailing Address - Zip Code:42602-1604
Mailing Address - Country:US
Mailing Address - Phone:606-387-3000
Mailing Address - Fax:606-387-3307
Practice Address - Street 1:250 BURKESVILLE RD
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:KY
Practice Address - Zip Code:42602-1604
Practice Address - Country:US
Practice Address - Phone:606-387-3000
Practice Address - Fax:606-387-3307
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY33185208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64033525Medicaid
KY64033525Medicaid
KYG63269Medicare UPIN