Provider Demographics
NPI:1164616892
Name:HIGHLANDS SURGICAL SERVICES LLC
Entity Type:Organization
Organization Name:HIGHLANDS SURGICAL SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SITARAMAKRISHNA
Authorized Official - Middle Name:
Authorized Official - Last Name:KOTHALANKA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:505-374-2521
Mailing Address - Street 1:315 N 3RD AVE
Mailing Address - Street 2:
Mailing Address - City:CLAYTON
Mailing Address - State:NM
Mailing Address - Zip Code:88415-3300
Mailing Address - Country:US
Mailing Address - Phone:505-374-2521
Mailing Address - Fax:505-374-2498
Practice Address - Street 1:315 N 3RD AVE
Practice Address - Street 2:
Practice Address - City:CLAYTON
Practice Address - State:NM
Practice Address - Zip Code:88415-3300
Practice Address - Country:US
Practice Address - Phone:505-374-2521
Practice Address - Fax:505-374-2498
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-06
Last Update Date:2007-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMMD2007-0129208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1184644080OtherINDIVIDUAL NPI
NM32537034Medicaid
NM32537034Medicaid