Provider Demographics
NPI:1336323971
Name:ADVANCED SURGICAL ASSOCIATES
Entity Type:Organization
Organization Name:ADVANCED SURGICAL ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIE
Authorized Official - Middle Name:
Authorized Official - Last Name:GOFFNEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:562-930-3841
Mailing Address - Street 1:3300 E SOUTH ST
Mailing Address - Street 2:#201
Mailing Address - City:LAKEWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90805-4588
Mailing Address - Country:US
Mailing Address - Phone:562-531-9272
Mailing Address - Fax:562-408-0346
Practice Address - Street 1:3300 E SOUTH ST
Practice Address - Street 2:#201
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90805-4588
Practice Address - Country:US
Practice Address - Phone:562-531-9272
Practice Address - Fax:562-408-0346
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-18
Last Update Date:2015-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG52590174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW11565Medicare PIN