Provider Demographics
NPI:1689618704
Name:FOUNDATION SURGERY AFFILLIATE OF GRAYSON COUNTY, LLC
Entity Type:Organization
Organization Name:FOUNDATION SURGERY AFFILLIATE OF GRAYSON COUNTY, LLC
Other - Org Name:HERITAGE PARK SURGERY CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CLINICAL MANAGER/ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:DEANN
Authorized Official - Middle Name:
Authorized Official - Last Name:SUTTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:903-813-3700
Mailing Address - Street 1:PO BOX 20603
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73156-0603
Mailing Address - Country:US
Mailing Address - Phone:405-608-1700
Mailing Address - Fax:405-608-1817
Practice Address - Street 1:3603 CALAIS DRIVE
Practice Address - Street 2:
Practice Address - City:SHERMAN
Practice Address - State:TX
Practice Address - Zip Code:75090
Practice Address - Country:US
Practice Address - Phone:903-813-3700
Practice Address - Fax:903-813-3701
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-16
Last Update Date:2009-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX008266261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1766065Medicaid
TXASC266Medicare ID - Type Unspecified