Provider Demographics
NPI:1831715143
Name:SURGICAL SPECIALTY ASSOCIATES, PLLC
Entity type:Organization
Organization Name:SURGICAL SPECIALTY ASSOCIATES, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:NATHAN
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:FIERCE
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:563-940-0537
Mailing Address - Street 1:870 36TH AVE
Mailing Address - Street 2:
Mailing Address - City:MOLINE
Mailing Address - State:IL
Mailing Address - Zip Code:61265-7159
Mailing Address - Country:US
Mailing Address - Phone:563-940-0537
Mailing Address - Fax:
Practice Address - Street 1:870 36TH AVE
Practice Address - Street 2:
Practice Address - City:MOLINE
Practice Address - State:IL
Practice Address - Zip Code:61265-7159
Practice Address - Country:US
Practice Address - Phone:563-940-0537
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-06-23
Last Update Date:2020-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036.127839Medicaid