Provider Demographics
NPI:1093865214
Name:ANGELINA SURGICAL ASSOCIATES
Entity Type:Organization
Organization Name:ANGELINA SURGICAL ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:BETTY
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:WHITE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:936-634-8216
Mailing Address - Street 1:PO BOX 150507
Mailing Address - Street 2:
Mailing Address - City:LUFKIN
Mailing Address - State:TX
Mailing Address - Zip Code:75915-0507
Mailing Address - Country:US
Mailing Address - Phone:936-634-8216
Mailing Address - Fax:936-634-8723
Practice Address - Street 1:302 MEDICAL PARK DR
Practice Address - Street 2:SUITE 101
Practice Address - City:LUFKIN
Practice Address - State:TX
Practice Address - Zip Code:75904-3148
Practice Address - Country:US
Practice Address - Phone:936-634-8216
Practice Address - Fax:936-634-8723
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-11
Last Update Date:2013-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0010EVOtherBLUE CROSS
TX079667401Medicaid
TX0010EVOtherBLUE CROSS