Provider Demographics
NPI:1609963065
Name:STARKVILLE SURGICAL CLINIC PA
Entity Type:Organization
Organization Name:STARKVILLE SURGICAL CLINIC PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RAYMOND
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:ORGLER
Authorized Official - Suffix:SR
Authorized Official - Credentials:MD
Authorized Official - Phone:662-773-8574
Mailing Address - Street 1:PO BOX 358
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:39339-0358
Mailing Address - Country:US
Mailing Address - Phone:662-773-8574
Mailing Address - Fax:662-773-7934
Practice Address - Street 1:547 E MAIN ST
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:MS
Practice Address - Zip Code:39339-0358
Practice Address - Country:US
Practice Address - Phone:663-773-8574
Practice Address - Fax:662-773-7934
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS08215208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09011566Medicaid
MS00119388Medicaid
B66194Medicare UPIN