Provider Demographics
NPI:1184843237
Name:EAST METRO SURGICAL ASSISTING
Entity Type:Organization
Organization Name:EAST METRO SURGICAL ASSISTING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TERESA
Authorized Official - Middle Name:
Authorized Official - Last Name:BOUTWELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-985-4257
Mailing Address - Street 1:PO BOX 1938
Mailing Address - Street 2:
Mailing Address - City:CONYERS
Mailing Address - State:GA
Mailing Address - Zip Code:30012-7291
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:70 ASHFORD DR
Practice Address - Street 2:
Practice Address - City:OXFORD
Practice Address - State:GA
Practice Address - Zip Code:30054-4648
Practice Address - Country:US
Practice Address - Phone:770-985-4257
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-25
Last Update Date:2008-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgicalGroup - Multi-Specialty