Provider Demographics
NPI:1770524878
Name:CENTER FOR SURGICAL SPECIALTIES, LLC
Entity type:Organization
Organization Name:CENTER FOR SURGICAL SPECIALTIES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DOMENIC
Authorized Official - Middle Name:M
Authorized Official - Last Name:CANONICO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:931-684-3504
Mailing Address - Street 1:310 COLLOREDO BLVD
Mailing Address - Street 2:STE B
Mailing Address - City:SHELBYVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37160
Mailing Address - Country:US
Mailing Address - Phone:931-684-3504
Mailing Address - Fax:931-684-5122
Practice Address - Street 1:310 COLLOREDO BLVD
Practice Address - Street 2:STE B
Practice Address - City:SHELBYVILLE
Practice Address - State:TN
Practice Address - Zip Code:37160
Practice Address - Country:US
Practice Address - Phone:931-684-3504
Practice Address - Fax:931-684-5122
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-09
Last Update Date:2013-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0000000128261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3288771E3739743Medicaid
TN4052519OtherBCBST
TN3288771E3739743Medicaid