Provider Demographics
NPI:1780068460
Name:SURGERY CLINIC, LLC
Entity type:Organization
Organization Name:SURGERY CLINIC, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:DIANETTE
Authorized Official - Middle Name:
Authorized Official - Last Name:KEENER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:256-547-6331
Mailing Address - Street 1:419 S 5TH ST
Mailing Address - Street 2:
Mailing Address - City:GADSDEN
Mailing Address - State:AL
Mailing Address - Zip Code:35901-5101
Mailing Address - Country:US
Mailing Address - Phone:256-547-6331
Mailing Address - Fax:256-547-1711
Practice Address - Street 1:1622 CHURCH AVE SE
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:AL
Practice Address - Zip Code:36265-3200
Practice Address - Country:US
Practice Address - Phone:256-547-6331
Practice Address - Fax:256-547-1711
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SURGERY CLINIC, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-07-13
Last Update Date:2021-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL208600000X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL528202650Medicaid
AL528202650Medicaid