Provider Demographics
NPI:1407032055
Name:PIEDMONT SURGICAL CLINIC, PA
Entity Type:Organization
Organization Name:PIEDMONT SURGICAL CLINIC, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:TAMMY
Authorized Official - Middle Name:S
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-786-1104
Mailing Address - Street 1:431 COPPERFIELD BLVD NE
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:NC
Mailing Address - Zip Code:28025-2405
Mailing Address - Country:US
Mailing Address - Phone:704-786-1104
Mailing Address - Fax:704-788-3112
Practice Address - Street 1:431 COPPERFIELD BLVD NE
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:NC
Practice Address - Zip Code:28025-3035
Practice Address - Country:US
Practice Address - Phone:704-786-1104
Practice Address - Fax:704-788-3112
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-14
Last Update Date:2012-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
No2086S0127XAllopathic & Osteopathic PhysiciansSurgeryTrauma SurgeryGroup - Single Specialty
No2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8902422Medicaid
NC8902422Medicaid