Provider Demographics
NPI:1447286810
Name:JEFFERSON SURGICAL CLINIC INC
Entity type:Organization
Organization Name:JEFFERSON SURGICAL CLINIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SHANNON
Authorized Official - Middle Name:C
Authorized Official - Last Name:BOWEN
Authorized Official - Suffix:
Authorized Official - Credentials:CCS-P
Authorized Official - Phone:540-283-6071
Mailing Address - Street 1:1234 FRANKLIN RD SW
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24016-4606
Mailing Address - Country:US
Mailing Address - Phone:540-283-6071
Mailing Address - Fax:540-283-6098
Practice Address - Street 1:1234 FRANKLIN RD SW
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24016-4606
Practice Address - Country:US
Practice Address - Phone:540-283-6071
Practice Address - Fax:540-283-6098
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-25
Last Update Date:2013-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAC06210Medicare PIN