Provider Demographics
NPI:1083639009
Name:SURGEON'S INC
Entity Type:Organization
Organization Name:SURGEON'S INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:D
Authorized Official - Last Name:LICATA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:740-266-3595
Mailing Address - Street 1:4000 JOHNSON RD FL 2
Mailing Address - Street 2:
Mailing Address - City:STEUBENVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43952-2364
Mailing Address - Country:US
Mailing Address - Phone:740-266-5959
Mailing Address - Fax:740-266-5957
Practice Address - Street 1:4000 JOHNSON RD FL 2
Practice Address - Street 2:
Practice Address - City:STEUBENVILLE
Practice Address - State:OH
Practice Address - Zip Code:43952-2364
Practice Address - Country:US
Practice Address - Phone:740-266-5959
Practice Address - Fax:740-266-5957
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-12
Last Update Date:2019-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV18107208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV00013780000Medicaid
OH0416964Medicaid
WV9913723Medicare PIN
OH9913724Medicare PIN
WV00013780000Medicaid