Provider Demographics
NPI:1891028395
Name:ADVANCED SURGICAL ASSOCIATES OF EAST TEXAS
Entity Type:Organization
Organization Name:ADVANCED SURGICAL ASSOCIATES OF EAST TEXAS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:DEWAYNE
Authorized Official - Last Name:MCCLAIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:608-443-9420
Mailing Address - Street 1:617 RUSSELL BLVD
Mailing Address - Street 2:
Mailing Address - City:NACOGDOCHES
Mailing Address - State:TX
Mailing Address - Zip Code:75965-1247
Mailing Address - Country:US
Mailing Address - Phone:936-205-5900
Mailing Address - Fax:936-205-5909
Practice Address - Street 1:617 RUSSELL BLVD
Practice Address - Street 2:
Practice Address - City:NACOGDOCHES
Practice Address - State:TX
Practice Address - Zip Code:75965-1247
Practice Address - Country:US
Practice Address - Phone:936-205-5900
Practice Address - Fax:936-205-5909
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-15
Last Update Date:2009-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN3408208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty