Provider Demographics
NPI:1669454245
Name:UNIVERSITY SURGICAL ASSOCIATES, P.C.
Entity Type:Organization
Organization Name:UNIVERSITY SURGICAL ASSOCIATES, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RANDY
Authorized Official - Middle Name:W
Authorized Official - Last Name:COOPER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:706-722-2334
Mailing Address - Street 1:818 SAINT SEBASTIAN WAY
Mailing Address - Street 2:SUITE 408
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30901-2651
Mailing Address - Country:US
Mailing Address - Phone:706-722-2334
Mailing Address - Fax:706-724-7032
Practice Address - Street 1:818 SAINT SEBASTIAN WAY
Practice Address - Street 2:SUITE 408
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30901-2651
Practice Address - Country:US
Practice Address - Phone:706-722-2334
Practice Address - Fax:706-724-7032
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-18
Last Update Date:2011-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGPA859Medicaid
GAGRP613Medicare ID - Type UnspecifiedMEDICARE GROUP ID#