Provider Demographics
NPI:1336143171
Name:THE SURGERY CENTER OF GEORGIA, LLC
Entity Type:Organization
Organization Name:THE SURGERY CENTER OF GEORGIA, LLC
Other - Org Name:ADVANCED SURGERY CENTER OF GEORGIA,LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:JUDITH
Authorized Official - Middle Name:
Authorized Official - Last Name:GRADY
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:770-479-2202
Mailing Address - Street 1:220 HOSPITAL RD
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:GA
Mailing Address - Zip Code:30114-2407
Mailing Address - Country:US
Mailing Address - Phone:770-479-2202
Mailing Address - Fax:770-479-3891
Practice Address - Street 1:220 HOSPITAL RD
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:GA
Practice Address - Zip Code:30114-2407
Practice Address - Country:US
Practice Address - Phone:770-479-2202
Practice Address - Fax:770-479-3891
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-09
Last Update Date:2008-07-14
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
GA1282933OtherUNITED HEALTHCARE
GA000659733AMedicaid
GA111040ASCAMedicare PIN