Provider Demographics
NPI:1689714784
Name:MIDTOWN SURGICAL ASSOCIATES, INC
Entity Type:Organization
Organization Name:MIDTOWN SURGICAL ASSOCIATES, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:DUANE
Authorized Official - Middle Name:
Authorized Official - Last Name:PRICKETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-872-8799
Mailing Address - Street 1:PO BOX 79105
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30357-7105
Mailing Address - Country:US
Mailing Address - Phone:404-872-8799
Mailing Address - Fax:404-874-3544
Practice Address - Street 1:95 COLLIER RD NW
Practice Address - Street 2:SUITE 4025
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30309-1796
Practice Address - Country:US
Practice Address - Phone:404-872-8799
Practice Address - Fax:404-874-3544
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-07
Last Update Date:2008-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN147341163WR0006X
GARN173288163WR0006X
GARN150639163WR0006X
GARN107268163WR0006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163WR0006XNursing Service ProvidersRegistered NurseRegistered Nurse First AssistantGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1528113370OtherNPI
GA1770633737OtherNPI
GA1801946876OtherNPI
GA52805990OtherBCBS ID #
GA52058526OtherBCBS ID #
GA1669538245OtherNPI
GA52703540OtherBCBS ID #