Provider Demographics
NPI:1275040008
Name:GM SURGICAL ASSISTANT INC
Entity Type:Organization
Organization Name:GM SURGICAL ASSISTANT INC
Other - Org Name:GM SURGICAL ASSISTANT INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BILLING ADMIN
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:SEVILLA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:909-346-0807
Mailing Address - Street 1:15615 TURNBERRY ST
Mailing Address - Street 2:
Mailing Address - City:MORENO VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92555-4901
Mailing Address - Country:US
Mailing Address - Phone:951-992-6201
Mailing Address - Fax:
Practice Address - Street 1:15615 TURNBERRY ST
Practice Address - Street 2:
Practice Address - City:MORENO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92555-4901
Practice Address - Country:US
Practice Address - Phone:951-992-6201
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-02
Last Update Date:2018-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA22985363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA=========OtherTAX ID