Provider Demographics
NPI:1396987582
Name:SURGICAL PRACTICE FACILITY
Entity type:Organization
Organization Name:SURGICAL PRACTICE FACILITY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:NANCY
Authorized Official - Middle Name:
Authorized Official - Last Name:PEED
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:478-825-8691
Mailing Address - Street 1:701 BLUEBIRD BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT VALLEY
Mailing Address - State:GA
Mailing Address - Zip Code:31030-5085
Mailing Address - Country:US
Mailing Address - Phone:478-825-7000
Mailing Address - Fax:478-825-4485
Practice Address - Street 1:701 BLUEBIRD BLVD
Practice Address - Street 2:
Practice Address - City:FORT VALLEY
Practice Address - State:GA
Practice Address - Zip Code:31030-5085
Practice Address - Country:US
Practice Address - Phone:478-825-7000
Practice Address - Fax:478-825-4485
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-02
Last Update Date:2009-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty