Provider Demographics
NPI:1508144981
Name:PROVIDENT HEALTH SURGICAL ASSOCIATES
Entity Type:Organization
Organization Name:PROVIDENT HEALTH SURGICAL ASSOCIATES
Other - Org Name:ACI SURGICAL ASSOCIATES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PROVIDER ENROLLMENT COORDINATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:ROBIN
Authorized Official - Middle Name:J
Authorized Official - Last Name:MADDOX
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:912-350-9335
Mailing Address - Street 1:4700 WATERS AVE
Mailing Address - Street 2:SUITE 403
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31404-6220
Mailing Address - Country:US
Mailing Address - Phone:912-350-2299
Mailing Address - Fax:912-350-2298
Practice Address - Street 1:4700 WATERS AVE
Practice Address - Street 2:SUITE 403
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31404-6220
Practice Address - Country:US
Practice Address - Phone:912-350-2299
Practice Address - Fax:912-350-2298
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-02
Last Update Date:2011-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
No2086X0206XAllopathic & Osteopathic PhysiciansSurgerySurgical OncologyGroup - Multi-Specialty