Provider Demographics
NPI:1851660443
Name:PALMYRA SURGICAL, LLC
Entity Type:Organization
Organization Name:PALMYRA SURGICAL, LLC
Other - Org Name:PALMYRA SURGICAL, LLC (MACON)
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:VITO
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:BAGNATO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:229-432-8484
Mailing Address - Street 1:810 13TH AVE STE 108
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:GA
Mailing Address - Zip Code:31701-1333
Mailing Address - Country:US
Mailing Address - Phone:229-432-8484
Mailing Address - Fax:229-432-8487
Practice Address - Street 1:420 CHARTER BLVD
Practice Address - Street 2:SUITE 103
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31210-4854
Practice Address - Country:US
Practice Address - Phone:229-432-8484
Practice Address - Fax:229-432-8487
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-28
Last Update Date:2011-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA45711208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09936OtherMISSISSIPPI LICENSE NUMBER
MS09936OtherMISSISSIPPI LICENSE NUMBER