Provider Demographics
NPI:1205374022
Name:GEORGIA AMBULATORY SURGERY CENTER LLC
Entity Type:Organization
Organization Name:GEORGIA AMBULATORY SURGERY CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:DORIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:JIMENEZ
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:770-979-0900
Mailing Address - Street 1:PO BOX 527
Mailing Address - Street 2:
Mailing Address - City:SNELLVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30078-0527
Mailing Address - Country:US
Mailing Address - Phone:770-979-0900
Mailing Address - Fax:770-979-2852
Practice Address - Street 1:2175 NORTH RD
Practice Address - Street 2:
Practice Address - City:SNELLVILLE
Practice Address - State:GA
Practice Address - Zip Code:30078-2630
Practice Address - Country:US
Practice Address - Phone:770-979-0900
Practice Address - Fax:770-979-2852
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-01
Last Update Date:2017-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA111126ASCAMedicare PIN