Provider Demographics
NPI:1528193505
Name:SURGERY MANAGEMENT SERVICES, INC
Entity Type:Organization
Organization Name:SURGERY MANAGEMENT SERVICES, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:L
Authorized Official - Last Name:RUDOLPH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:304-424-2102
Mailing Address - Street 1:PO BOX 183
Mailing Address - Street 2:
Mailing Address - City:PARKERSBURG
Mailing Address - State:WV
Mailing Address - Zip Code:26102-0183
Mailing Address - Country:US
Mailing Address - Phone:304-424-2102
Mailing Address - Fax:304-424-2103
Practice Address - Street 1:705 GARFIELD AVE
Practice Address - Street 2:SUITE 440
Practice Address - City:PARKERSBURY
Practice Address - State:WV
Practice Address - Zip Code:26102-0183
Practice Address - Country:US
Practice Address - Phone:304-424-2102
Practice Address - Fax:304-424-2103
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-22
Last Update Date:2008-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV12909208600000X, 2086S0102X, 208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
No2086S0102XAllopathic & Osteopathic PhysiciansSurgerySurgical Critical CareGroup - Multi-Specialty
No208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)Group - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0587304Medicare PIN