Provider Demographics
NPI:1255003455
Name:ICON SURGICAL
Entity Type:Organization
Organization Name:ICON SURGICAL
Other - Org Name:ICON SURGICAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:PAMELA
Authorized Official - Middle Name:
Authorized Official - Last Name:CLAY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:888-265-9908
Mailing Address - Street 1:268 SAINT PATRICK DR SW
Mailing Address - Street 2:
Mailing Address - City:MABLETON
Mailing Address - State:GA
Mailing Address - Zip Code:30126-1627
Mailing Address - Country:US
Mailing Address - Phone:678-825-5397
Mailing Address - Fax:678-426-6243
Practice Address - Street 1:268 SAINT PATRICK DR SW
Practice Address - Street 2:
Practice Address - City:MABLETON
Practice Address - State:GA
Practice Address - Zip Code:30126-1627
Practice Address - Country:US
Practice Address - Phone:678-825-5397
Practice Address - Fax:678-426-6243
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-10-05
Last Update Date:2024-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgicalGroup - Multi-Specialty