Basic Information
| Provider Information | |||||||||
| NPI: | 1790043453 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PREFERRED SURGICAL ASSOCIATES | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1349 | ||||||||
| Address2: | |||||||||
| City: | NEW TAXWELL | ||||||||
| State: | TN | ||||||||
| PostalCode: | 378251349 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8656706199 | ||||||||
| FaxNumber: | 8656706188 | ||||||||
| Practice Location | |||||||||
| Address1: | 1610 TAZEWELL RD | ||||||||
| Address2: | STE 301 | ||||||||
| City: | TAZEWELL | ||||||||
| State: | TN | ||||||||
| PostalCode: | 378793600 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4236264288 | ||||||||
| FaxNumber: | 4236261101 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/01/2012 | ||||||||
| LastUpdateDate: | 06/29/2012 | ||||||||
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| AuthorizedOfficialLastName: | WILMOTH | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
| AuthorizedOfficialMiddleName: | J. | ||||||||
| AuthorizedOfficialTitleorPosition: | SOLE OWNER | ||||||||
| AuthorizedOfficialTelephone: | 4236264288 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | TN | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 1527909 | 05 | TN | MEDICAID |