Provider Demographics
NPI:1326497470
Name:PHOENIX SURGICAL SERVICES
Entity Type:Organization
Organization Name:PHOENIX SURGICAL SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:ALFONSO
Authorized Official - Middle Name:JOSE
Authorized Official - Last Name:BRAVO
Authorized Official - Suffix:
Authorized Official - Credentials:LSA
Authorized Official - Phone:832-512-4011
Mailing Address - Street 1:4803 HACKAMORE BROOK CT
Mailing Address - Street 2:
Mailing Address - City:KATY
Mailing Address - State:TX
Mailing Address - Zip Code:77449-5377
Mailing Address - Country:US
Mailing Address - Phone:832-512-4011
Mailing Address - Fax:
Practice Address - Street 1:4803 HACKAMORE BROOK CT
Practice Address - Street 2:
Practice Address - City:KATY
Practice Address - State:TX
Practice Address - Zip Code:77449-5377
Practice Address - Country:US
Practice Address - Phone:832-512-4011
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-09
Last Update Date:2016-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXSA00284363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgicalGroup - Multi-Specialty