Provider Demographics
NPI:1588614028
Name:DANVILLE SURGICAL ASSOCIATES PLLC
Entity Type:Organization
Organization Name:DANVILLE SURGICAL ASSOCIATES PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ANNE SHANNON
Authorized Official - Middle Name:
Authorized Official - Last Name:BECKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:859-236-0712
Mailing Address - Street 1:210 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40422-1812
Mailing Address - Country:US
Mailing Address - Phone:859-236-0712
Mailing Address - Fax:859-236-7858
Practice Address - Street 1:210 W MAIN ST
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:KY
Practice Address - Zip Code:40422-1812
Practice Address - Country:US
Practice Address - Phone:859-236-0712
Practice Address - Fax:859-236-7858
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-12
Last Update Date:2011-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY24455208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64244551Medicaid
KY0320502Medicare ID - Type Unspecified
KYC75720Medicare UPIN