Provider Demographics
NPI:1801956859
Name:NORTHEAST SURGICAL SPECIALTIES, LLC
Entity type:Organization
Organization Name:NORTHEAST SURGICAL SPECIALTIES, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SR VP
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:F
Authorized Official - Last Name:LAYMON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-403-2276
Mailing Address - Street 1:1090 NORTHEAST GATEWAY COURT NE
Mailing Address - Street 2:SUITE 204
Mailing Address - City:CONCORD
Mailing Address - State:NC
Mailing Address - Zip Code:28025-2440
Mailing Address - Country:US
Mailing Address - Phone:704-403-7020
Mailing Address - Fax:704-403-7039
Practice Address - Street 1:1090 NORTHEAST GATEWAY COURT NE
Practice Address - Street 2:SUITE 204
Practice Address - City:CONCORD
Practice Address - State:NC
Practice Address - Zip Code:28025-2440
Practice Address - Country:US
Practice Address - Phone:704-403-7020
Practice Address - Fax:704-403-7039
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NORTHEAST SURGICAL SPECIALTIES, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-12-11
Last Update Date:2016-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC018W5OtherBCBS
NC5906976Medicaid
NCDO1210OtherRAILROAD MEDICARE PTAN
NCDO1210OtherRAILROAD MEDICARE PTAN