Provider Demographics
NPI:1366444929
Name:EAST WEST SURGERY CENTER LP
Entity Type:Organization
Organization Name:EAST WEST SURGERY CENTER LP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICER / AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:JENETHA
Authorized Official - Middle Name:D
Authorized Official - Last Name:MORAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:972-763-3893
Mailing Address - Street 1:2041 MESA VALLEY WAY
Mailing Address - Street 2:STE 125
Mailing Address - City:AUSTELL
Mailing Address - State:GA
Mailing Address - Zip Code:30106-6828
Mailing Address - Country:US
Mailing Address - Phone:678-309-8100
Mailing Address - Fax:678-309-8101
Practice Address - Street 1:2041 MESA VALLEY WAY
Practice Address - Street 2:STE 125
Practice Address - City:AUSTELL
Practice Address - State:GA
Practice Address - Zip Code:30106-6828
Practice Address - Country:US
Practice Address - Phone:678-309-8100
Practice Address - Fax:678-309-8101
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-12
Last Update Date:2018-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA033202261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA327221OtherMEDICAID WELLCARE
GA68-00053OtherUNITED HEALTHCARE
GA7467086OtherAETNA PPO
GA490005006OtherRR MEDICARE
GA00897047AMedicaid
GA2377093OtherAETNA H/POS
GA51795413002OtherBLUE CROSS
GA166-510-500OtherDEPT OF LABOR
GA7467086OtherAETNA PPO