Provider Demographics
NPI:1710319017
Name:PREMIERE SURGICAL SPECIALISTS, A PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:PREMIERE SURGICAL SPECIALISTS, A PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:ALLEN
Authorized Official - Last Name:COX
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:626-449-4859
Mailing Address - Street 1:35 E GLENARM ST
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91105-3418
Mailing Address - Country:US
Mailing Address - Phone:626-449-4859
Mailing Address - Fax:626-403-0311
Practice Address - Street 1:950 S ARROYO PKWY STE 310
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91105-3930
Practice Address - Country:US
Practice Address - Phone:626-449-4859
Practice Address - Fax:626-403-0311
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-08-08
Last Update Date:2022-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
No2086X0206XAllopathic & Osteopathic PhysiciansSurgerySurgical OncologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA11713OtherCITY OF GLENDORA LICENSE