Provider Demographics
NPI:1982069068
Name:RAIDER SURGICAL CENTER LLC
Entity Type:Organization
Organization Name:RAIDER SURGICAL CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:WADE
Authorized Official - Middle Name:A
Authorized Official - Last Name:GRAHAM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:956-429-4900
Mailing Address - Street 1:1519 E 6TH ST
Mailing Address - Street 2:
Mailing Address - City:WESLACO
Mailing Address - State:TX
Mailing Address - Zip Code:78596-6605
Mailing Address - Country:US
Mailing Address - Phone:956-429-4900
Mailing Address - Fax:956-429-4901
Practice Address - Street 1:1400 E RIDGE RD STE 3
Practice Address - Street 2:
Practice Address - City:MCALLEN
Practice Address - State:TX
Practice Address - Zip Code:78503-1536
Practice Address - Country:US
Practice Address - Phone:956-429-4900
Practice Address - Fax:956-429-4901
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-16
Last Update Date:2017-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX130305261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical