Provider Demographics
NPI:1437121050
Name:THE SURGICAL CLINIC OF ANNISTON, PA
Entity Type:Organization
Organization Name:THE SURGICAL CLINIC OF ANNISTON, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN CREDENTIALING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JILL
Authorized Official - Middle Name:G
Authorized Official - Last Name:SISSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:256-237-1624
Mailing Address - Street 1:PO BOX 5430
Mailing Address - Street 2:
Mailing Address - City:ANNISTON
Mailing Address - State:AL
Mailing Address - Zip Code:36205-0430
Mailing Address - Country:US
Mailing Address - Phone:256-241-6310
Mailing Address - Fax:256-241-2277
Practice Address - Street 1:111 TOWN CENTER DRIVE
Practice Address - Street 2:
Practice Address - City:ANNISTON
Practice Address - State:AL
Practice Address - Zip Code:36205-4102
Practice Address - Country:US
Practice Address - Phone:256-237-1624
Practice Address - Fax:256-241-2277
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-07
Last Update Date:2022-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL528200290Medicaid
AL528200290Medicaid