Provider Demographics
NPI:1639459027
Name:PIEDMONT GENERAL SURGERY ASSOCIATES, LLC
Entity Type:Organization
Organization Name:PIEDMONT GENERAL SURGERY ASSOCIATES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SVP OF OUTPATIENT SERVICES, TENET
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:KYLE
Authorized Official - Last Name:BURTNETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:469-893-2153
Mailing Address - Street 1:PO BOX 741841
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-1841
Mailing Address - Country:US
Mailing Address - Phone:803-909-6300
Mailing Address - Fax:803-909-6310
Practice Address - Street 1:200 S HERLONG AVE
Practice Address - Street 2:SUITE G
Practice Address - City:ROCK HILL
Practice Address - State:SC
Practice Address - Zip Code:29732-3399
Practice Address - Country:US
Practice Address - Phone:803-909-6300
Practice Address - Fax:803-909-6310
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-17
Last Update Date:2013-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP5793Medicaid
SCGP5793Medicaid