Provider Demographics
NPI:1720315393
Name:WALTHALL SURGICAL CENTER PLLC
Entity Type:Organization
Organization Name:WALTHALL SURGICAL CENTER PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/OPERATOR
Authorized Official - Prefix:DR
Authorized Official - First Name:ELLEN
Authorized Official - Middle Name:D
Authorized Official - Last Name:WALTHALL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:325-236-8886
Mailing Address - Street 1:301 JENNY GEORGE LN
Mailing Address - Street 2:
Mailing Address - City:SWEETWATER
Mailing Address - State:TX
Mailing Address - Zip Code:79556-7152
Mailing Address - Country:US
Mailing Address - Phone:325-236-8886
Mailing Address - Fax:325-236-8861
Practice Address - Street 1:301 JENNY GEORGE LN
Practice Address - Street 2:
Practice Address - City:SWEETWATER
Practice Address - State:TX
Practice Address - Zip Code:79556-7152
Practice Address - Country:US
Practice Address - Phone:325-236-8886
Practice Address - Fax:325-236-8861
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-11-03
Last Update Date:2009-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ0343208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty