Provider Demographics
NPI:1417224650
Name:SOUTHERN SURGICAL ASSISTANTS LLC
Entity Type:Organization
Organization Name:SOUTHERN SURGICAL ASSISTANTS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:
Authorized Official - Last Name:KANCLERZ
Authorized Official - Suffix:
Authorized Official - Credentials:RNFA
Authorized Official - Phone:678-591-8344
Mailing Address - Street 1:PO BOX 7042
Mailing Address - Street 2:
Mailing Address - City:CHESTNUT MOUNTAIN
Mailing Address - State:GA
Mailing Address - Zip Code:30502-0042
Mailing Address - Country:US
Mailing Address - Phone:678-591-8344
Mailing Address - Fax:
Practice Address - Street 1:1200 NORTHSIDE FORSYTH DR
Practice Address - Street 2:
Practice Address - City:CUMMING
Practice Address - State:GA
Practice Address - Zip Code:30041-7659
Practice Address - Country:US
Practice Address - Phone:770-844-3200
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-16
Last Update Date:2015-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN177592363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty