Provider Demographics
NPI:1013084631
Name:FAYETTEVILLE SURGICAL ASSOC PA
Entity Type:Organization
Organization Name:FAYETTEVILLE SURGICAL ASSOC PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINIC ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:GWEN
Authorized Official - Middle Name:S
Authorized Official - Last Name:MATHIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:479-521-3300
Mailing Address - Street 1:3264 N. NORTH HILLS BLVD.
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72703-4005
Mailing Address - Country:US
Mailing Address - Phone:479-521-3300
Mailing Address - Fax:479-521-4914
Practice Address - Street 1:3264 N. NORTH HILLS BLVD.
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72703-4005
Practice Address - Country:US
Practice Address - Phone:479-521-3300
Practice Address - Fax:479-521-4914
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-29
Last Update Date:2013-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR111799002Medicaid
AR57127Medicare PIN