Provider Demographics
NPI:1881193183
Name:SOUTHSIDE SPECIALTY SURGICAL CENTER LLC
Entity Type:Organization
Organization Name:SOUTHSIDE SPECIALTY SURGICAL CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:GABRIEL
Authorized Official - Middle Name:
Authorized Official - Last Name:LOPEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:361-225-0089
Mailing Address - Street 1:6025 BROADMOOR DR
Mailing Address - Street 2:
Mailing Address - City:CORPUS CHRISTI
Mailing Address - State:TX
Mailing Address - Zip Code:78413-2714
Mailing Address - Country:US
Mailing Address - Phone:361-548-3334
Mailing Address - Fax:
Practice Address - Street 1:6005 HOLLY RD
Practice Address - Street 2:
Practice Address - City:CORPUS CHRISTI
Practice Address - State:TX
Practice Address - Zip Code:78412
Practice Address - Country:US
Practice Address - Phone:361-548-3334
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-02-02
Last Update Date:2019-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical