Provider Demographics
NPI:1871773549
Name:FAYETTE SURGICAL ASSOCIATES
Entity type:Organization
Organization Name:FAYETTE SURGICAL ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DIANA
Authorized Official - Middle Name:
Authorized Official - Last Name:LOWERY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-719-5660
Mailing Address - Street 1:1265 HIGHWAY 54 W
Mailing Address - Street 2:SUITE 500B
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30214-4548
Mailing Address - Country:US
Mailing Address - Phone:770-719-5660
Mailing Address - Fax:678-817-4339
Practice Address - Street 1:1265 HIGHWAY 54 W
Practice Address - Street 2:SUITE 500B
Practice Address - City:FAYETTEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30214-4548
Practice Address - Country:US
Practice Address - Phone:770-719-5660
Practice Address - Fax:678-817-4339
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-09
Last Update Date:2007-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GADA6744OtherRAILROAD MEDICARE
GAGRP6083Medicare PIN