Provider Demographics
NPI:1639345507
Name:WINDER SURGICAL SPECIALIST
Entity Type:Organization
Organization Name:WINDER SURGICAL SPECIALIST
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:CESAR
Authorized Official - Middle Name:MEDALLA
Authorized Official - Last Name:DELIMA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:770-307-1305
Mailing Address - Street 1:PO BOX 1169
Mailing Address - Street 2:
Mailing Address - City:WINDER
Mailing Address - State:GA
Mailing Address - Zip Code:30680-1169
Mailing Address - Country:US
Mailing Address - Phone:770-307-1305
Mailing Address - Fax:770-307-1522
Practice Address - Street 1:314 N BROAD ST
Practice Address - Street 2:SUITE 350
Practice Address - City:WINDER
Practice Address - State:GA
Practice Address - Zip Code:30680-2191
Practice Address - Country:US
Practice Address - Phone:770-307-1305
Practice Address - Fax:770-307-1522
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-01
Last Update Date:2008-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA028396208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000324244DMedicaid
GA52238010OtherBLUE CROSS BLUE SHIELD
GA000324244DMedicaid
GAD39721Medicare UPIN