Provider Demographics
NPI:1164441333
Name:PROFFER SURGICAL ASSOCIATES, LLP
Entity Type:Organization
Organization Name:PROFFER SURGICAL ASSOCIATES, LLP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:LIANA
Authorized Official - Middle Name:
Authorized Official - Last Name:PROFFER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:806-354-4900
Mailing Address - Street 1:1611 WALLACE BLVD
Mailing Address - Street 2:
Mailing Address - City:AMARILLO
Mailing Address - State:TX
Mailing Address - Zip Code:79106-1799
Mailing Address - Country:US
Mailing Address - Phone:806-354-4900
Mailing Address - Fax:806-352-4987
Practice Address - Street 1:1611 WALLACE BLVD
Practice Address - Street 2:
Practice Address - City:AMARILLO
Practice Address - State:TX
Practice Address - Zip Code:79106-1799
Practice Address - Country:US
Practice Address - Phone:806-354-4900
Practice Address - Fax:806-352-4987
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-19
Last Update Date:2013-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK6910207ND0101X
TXK3932207W00000X
TXM0532208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic SurgeryGroup - Multi-Specialty
No207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Multi-Specialty
No208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX187148501Medicaid
TX0021NJOtherBLUE CROSS BLUE SHIELD
TX00W663Medicare PIN