Provider Demographics
NPI:1588619811
Name:LAWRENCEVILLE SURGERY CENTER, LLC
Entity Type:Organization
Organization Name:LAWRENCEVILLE SURGERY CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:JENETHA
Authorized Official - Middle Name:D
Authorized Official - Last Name:MORAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:972-763-3893
Mailing Address - Street 1:758 OLD NORCROSS RD STE 125
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30046-3387
Mailing Address - Country:US
Mailing Address - Phone:678-987-0820
Mailing Address - Fax:678-987-0821
Practice Address - Street 1:758 OLD NORCROSS RD
Practice Address - Street 2:SUITE 125
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30046-3385
Practice Address - Country:US
Practice Address - Phone:678-987-0820
Practice Address - Fax:678-987-0821
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-24
Last Update Date:2019-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA067221261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA7813306OtherAETNA US HEALTHCARE
GA68-00058OtherUNITED HEALTHCARE
GA000923414AMedicaid
GA2633327OtherAETNA
GA913003OtherBLUE CROSS BLUE SHIELD
GA7813306OtherAETNA US HEALTHCARE
GA913003OtherBLUE CROSS BLUE SHIELD