Provider Demographics
NPI:1083122055
Name:PARK SURGICAL SPECIALISTS, LLC
Entity Type:Organization
Organization Name:PARK SURGICAL SPECIALISTS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:TERRI
Authorized Official - Middle Name:
Authorized Official - Last Name:MCDONALD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-414-8047
Mailing Address - Street 1:4255 JOHNS CREEK PKWY STE D
Mailing Address - Street 2:
Mailing Address - City:SUWANEE
Mailing Address - State:GA
Mailing Address - Zip Code:30024-6122
Mailing Address - Country:US
Mailing Address - Phone:404-414-8047
Mailing Address - Fax:
Practice Address - Street 1:4255 JOHNS CREEK PKWY STE D
Practice Address - Street 2:
Practice Address - City:SUWANEE
Practice Address - State:GA
Practice Address - Zip Code:30024-6122
Practice Address - Country:US
Practice Address - Phone:404-414-8047
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-12
Last Update Date:2018-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA32801174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty