Provider Demographics
NPI:1912947755
Name:EDMOND GENERAL SURGERY LLC
Entity Type:Organization
Organization Name:EDMOND GENERAL SURGERY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:M
Authorized Official - Last Name:SMITHAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:303-584-8000
Mailing Address - Street 1:4900 S MONACO ST
Mailing Address - Street 2:#210
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80237-3486
Mailing Address - Country:US
Mailing Address - Phone:303-584-8000
Mailing Address - Fax:303-584-8141
Practice Address - Street 1:4900 S MONACO ST
Practice Address - Street 2:#210
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80237-3486
Practice Address - Country:US
Practice Address - Phone:303-584-8000
Practice Address - Fax:303-584-8141
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-08
Last Update Date:2012-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200074050AMedicaid
OK500522146Medicare PIN
OK200074050AMedicaid