Provider Demographics
NPI:1649342031
Name:PRINCETON SURGICAL GROUP INC
Entity type:Organization
Organization Name:PRINCETON SURGICAL GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GENEROSO
Authorized Official - Middle Name:D
Authorized Official - Last Name:DUREMDES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:304-425-2310
Mailing Address - Street 1:508 NEW HOPE RD STE 106
Mailing Address - Street 2:
Mailing Address - City:PRINCETON
Mailing Address - State:WV
Mailing Address - Zip Code:24740-2265
Mailing Address - Country:US
Mailing Address - Phone:304-425-2310
Mailing Address - Fax:304-487-3675
Practice Address - Street 1:508 NEW HOPE RD STE 106
Practice Address - Street 2:
Practice Address - City:PRINCETON
Practice Address - State:WV
Practice Address - Zip Code:24740-2265
Practice Address - Country:US
Practice Address - Phone:304-425-2310
Practice Address - Fax:304-487-3675
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-14
Last Update Date:2014-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV16015208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0009321000Medicaid
WV0009321000Medicaid