Provider Demographics
NPI:1558859645
Name:EAST FREEDOM SURGICAL ASSOCIATES, LLC
Entity Type:Organization
Organization Name:EAST FREEDOM SURGICAL ASSOCIATES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MRS
Authorized Official - First Name:TINA
Authorized Official - Middle Name:
Authorized Official - Last Name:BURKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:814-623-0552
Mailing Address - Street 1:202 MEMORIAL DR STE 2
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:PA
Mailing Address - Zip Code:15537-7057
Mailing Address - Country:US
Mailing Address - Phone:814-935-8309
Mailing Address - Fax:814-623-0752
Practice Address - Street 1:15721 DUNNINGS HWY
Practice Address - Street 2:
Practice Address - City:DUNCANSVILLE
Practice Address - State:PA
Practice Address - Zip Code:16635
Practice Address - Country:US
Practice Address - Phone:814-623-0552
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-25
Last Update Date:2018-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS007645L208800000X
261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
No208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA=========OtherCOPY OF PA DEPT OF STATE BUREAU OF CORPORATIONS AND CHARITABLE ORGANIZATIONS