Provider Demographics
NPI:1114159357
Name:GUADALUPE VALLEY SURGICAL ASSOCIATES PA
Entity Type:Organization
Organization Name:GUADALUPE VALLEY SURGICAL ASSOCIATES PA
Other - Org Name:PERMIAN BASIN SURGICAL ASSOC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/MD
Authorized Official - Prefix:DR
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:WADE
Authorized Official - Last Name:FATH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:432-333-8400
Mailing Address - Street 1:420 E 6TH ST STE 104
Mailing Address - Street 2:
Mailing Address - City:ODESSA
Mailing Address - State:TX
Mailing Address - Zip Code:79761-4537
Mailing Address - Country:US
Mailing Address - Phone:432-333-8400
Mailing Address - Fax:432-333-8401
Practice Address - Street 1:420 E 6TH ST STE 104
Practice Address - Street 2:
Practice Address - City:ODESSA
Practice Address - State:TX
Practice Address - Zip Code:79761-4537
Practice Address - Country:US
Practice Address - Phone:432-333-8400
Practice Address - Fax:432-333-8401
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-21
Last Update Date:2011-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK8144208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX040430302Medicaid
TXG10563Medicare UPIN
TX040430302Medicaid