Provider Demographics
NPI:1922280197
Name:NORTH OAK AMBULATORY SURGERY CENTER, LLC
Entity Type:Organization
Organization Name:NORTH OAK AMBULATORY SURGERY CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:AVIS
Authorized Official - Middle Name:S
Authorized Official - Last Name:GRIFFIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:229-242-3668
Mailing Address - Street 1:2718 N OAK ST
Mailing Address - Street 2:
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31602-1781
Mailing Address - Country:US
Mailing Address - Phone:229-242-3668
Mailing Address - Fax:229-253-8666
Practice Address - Street 1:2718 N OAK ST
Practice Address - Street 2:
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31602-1781
Practice Address - Country:US
Practice Address - Phone:229-242-3668
Practice Address - Fax:229-253-8666
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-29
Last Update Date:2012-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA092-374261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003127038AMedicaid
GA11C0001035Medicare PIN