Provider Demographics
NPI:1083862882
Name:PROVIDENT HEALTH SURGICAL ASSOCIATES, INC.
Entity Type:Organization
Organization Name:PROVIDENT HEALTH SURGICAL ASSOCIATES, INC.
Other - Org Name:ACI SURGICAL ASSOCIATES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PROVIDER ENROLLMENT COORDINATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:ROBIN
Authorized Official - Middle Name:J
Authorized Official - Last Name:MADDOX
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:912-350-9335
Mailing Address - Street 1:PO BOX 102019
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30368-2019
Mailing Address - Country:US
Mailing Address - Phone:912-350-2299
Mailing Address - Fax:912-350-2298
Practice Address - Street 1:14 OKATIE CENTER BLVD. SOUTH
Practice Address - Street 2:SUITE 101
Practice Address - City:OKATIE
Practice Address - State:SC
Practice Address - Zip Code:29909
Practice Address - Country:US
Practice Address - Phone:912-350-2299
Practice Address - Fax:912-350-2298
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-04
Last Update Date:2011-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086X0206XAllopathic & Osteopathic PhysiciansSurgerySurgical OncologyGroup - Multi-Specialty
No207VX0201XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologic OncologyGroup - Multi-Specialty
No207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Multi-Specialty
No208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
No2086S0102XAllopathic & Osteopathic PhysiciansSurgerySurgical Critical CareGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP5024Medicaid
SCDO4198OtherRR MEDICARE
SC9141Medicare PIN