Provider Demographics
NPI:1114030129
Name:TYLERTOWN SURGICAL ASSOCIATES
Entity Type:Organization
Organization Name:TYLERTOWN SURGICAL ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:POSAVANIKE
Authorized Official - Middle Name:S
Authorized Official - Last Name:GANARAJ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:601-876-4961
Mailing Address - Street 1:250 HOSPITAL DR
Mailing Address - Street 2:P.0. BOX 465
Mailing Address - City:TYLERTOWN
Mailing Address - State:MS
Mailing Address - Zip Code:39667-2020
Mailing Address - Country:US
Mailing Address - Phone:601-876-4961
Mailing Address - Fax:601-876-9172
Practice Address - Street 1:250 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:TYLERTOWN
Practice Address - State:MS
Practice Address - Zip Code:39667-2020
Practice Address - Country:US
Practice Address - Phone:601-876-4961
Practice Address - Fax:601-876-9172
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS07415261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09016259Medicaid
MS09016259Medicaid
MS09016259Medicaid