Provider Demographics
NPI:1619372398
Name:KMC SURGICAL LLC
Entity Type:Organization
Organization Name:KMC SURGICAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:STARLA
Authorized Official - Middle Name:
Authorized Official - Last Name:STALLINGS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:706-737-7922
Mailing Address - Street 1:2320 WRIGHTSBORO RD
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30904-6233
Mailing Address - Country:US
Mailing Address - Phone:706-737-7922
Mailing Address - Fax:706-737-7968
Practice Address - Street 1:2320 WRIGHTSBORO RD
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30904-6233
Practice Address - Country:US
Practice Address - Phone:706-737-7922
Practice Address - Fax:706-737-7968
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-24
Last Update Date:2014-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA53781174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA585070845AMedicaid
GA585070845AMedicaid