Provider Demographics
NPI:1164093068
Name:CLEAVER MEDICAL GROUP SURGERY CENTER
Entity Type:Organization
Organization Name:CLEAVER MEDICAL GROUP SURGERY CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MIRANDA
Authorized Official - Middle Name:L
Authorized Official - Last Name:REED
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:770-800-3455
Mailing Address - Street 1:105 PROFESSIONAL PARK DR STE 200
Mailing Address - Street 2:
Mailing Address - City:CUMMING
Mailing Address - State:GA
Mailing Address - Zip Code:30040-2381
Mailing Address - Country:US
Mailing Address - Phone:770-800-3455
Mailing Address - Fax:770-284-8380
Practice Address - Street 1:105 PROFESSIONAL PARK DR STE 200
Practice Address - Street 2:
Practice Address - City:CUMMING
Practice Address - State:GA
Practice Address - Zip Code:30040-2381
Practice Address - Country:US
Practice Address - Phone:770-800-3455
Practice Address - Fax:770-284-8380
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-07-02
Last Update Date:2022-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAASTC001560Medicaid