Provider Demographics
NPI:1255000329
Name:GLENEAGLES SURGERY CENTER, LLC
Entity type:Organization
Organization Name:GLENEAGLES SURGERY CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DPM
Authorized Official - Prefix:
Authorized Official - First Name:JEREMIAH
Authorized Official - Middle Name:A
Authorized Official - Last Name:GRAFF
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:142-205-1078
Mailing Address - Street 1:2633 DALLAS PKWY STE 100
Mailing Address - Street 2:
Mailing Address - City:PLANO
Mailing Address - State:TX
Mailing Address - Zip Code:75093-4715
Mailing Address - Country:US
Mailing Address - Phone:972-403-7733
Mailing Address - Fax:972-403-7744
Practice Address - Street 1:2633 DALLAS PKWY STE 100
Practice Address - Street 2:
Practice Address - City:PLANO
Practice Address - State:TX
Practice Address - Zip Code:75093-4715
Practice Address - Country:US
Practice Address - Phone:972-403-7733
Practice Address - Fax:972-403-7744
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-09-10
Last Update Date:2021-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical