Provider Demographics
NPI:1548591076
Name:NOBLEJAZZ, INC
Entity Type:Organization
Organization Name:NOBLEJAZZ, INC
Other - Org Name:SURGICAL SPECIALISTS ASSOCIATED
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:WESLEY
Authorized Official - Middle Name:BLAKE
Authorized Official - Last Name:VANDERLAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:775-842-2903
Mailing Address - Street 1:3320 THOMASVILLE RD STE 302
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32308-7971
Mailing Address - Country:US
Mailing Address - Phone:775-842-2903
Mailing Address - Fax:
Practice Address - Street 1:3320 THOMASVILLE RD STE 302
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32308-7971
Practice Address - Country:US
Practice Address - Phone:775-842-2903
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-22
Last Update Date:2024-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVPENDINGMedicare PIN