Provider Demographics
NPI:1245690916
Name:JACKSON STREET SURGICAL CENTER LLC
Entity type:Organization
Organization Name:JACKSON STREET SURGICAL CENTER LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ADITY
Authorized Official - Middle Name:
Authorized Official - Last Name:SHARMA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:732-698-1000
Mailing Address - Street 1:2015 JACKSON STREET
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77003
Mailing Address - Country:US
Mailing Address - Phone:281-974-2300
Mailing Address - Fax:
Practice Address - Street 1:2015 JACKSON STREET
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77003
Practice Address - Country:US
Practice Address - Phone:281-974-2300
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-24
Last Update Date:2016-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX130278261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical