Provider Demographics
NPI:1578504700
Name:CARROLLTON SURGICAL GROUP, P. A.
Entity Type:Organization
Organization Name:CARROLLTON SURGICAL GROUP, P. A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:JAN
Authorized Official - Middle Name:M
Authorized Official - Last Name:ZEIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-537-4702
Mailing Address - Street 1:204 ALLEN MEMORIAL DR
Mailing Address - Street 2:SUITE 103
Mailing Address - City:BREMEN
Mailing Address - State:GA
Mailing Address - Zip Code:30110-2047
Mailing Address - Country:US
Mailing Address - Phone:770-537-4702
Mailing Address - Fax:770-537-4539
Practice Address - Street 1:204 ALLEN MEMORIAL DR
Practice Address - Street 2:SUITE 103
Practice Address - City:BREMEN
Practice Address - State:GA
Practice Address - Zip Code:30110-2047
Practice Address - Country:US
Practice Address - Phone:770-537-4702
Practice Address - Fax:770-537-4539
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA55001589AMedicaid
GA55001589AMedicaid