Provider Demographics
NPI:1487027504
Name:ADVANCED SURGICAL ASSISTANTS LLC
Entity Type:Organization
Organization Name:ADVANCED SURGICAL ASSISTANTS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SURGICAL FIRST ASSISTANT
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:GILLUM
Authorized Official - Suffix:JR
Authorized Official - Credentials:SFA
Authorized Official - Phone:228-343-3044
Mailing Address - Street 1:1924 30TH AVE STE A
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39501-4534
Mailing Address - Country:US
Mailing Address - Phone:228-206-7634
Mailing Address - Fax:228-206-4523
Practice Address - Street 1:1924 30TH AVE STE A
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39501-4534
Practice Address - Country:US
Practice Address - Phone:228-206-7634
Practice Address - Fax:228-206-4523
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-11-11
Last Update Date:2015-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgicalGroup - Multi-Specialty