Provider Demographics
NPI:1306830195
Name:FOUNDATION SURGERY AFFILIATES OF HUNTSVILLE
Entity type:Organization
Organization Name:FOUNDATION SURGERY AFFILIATES OF HUNTSVILLE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:TAVA
Authorized Official - Middle Name:
Authorized Official - Last Name:FOGLE
Authorized Official - Suffix:
Authorized Official - Credentials:RN, BSN
Authorized Official - Phone:936-291-3200
Mailing Address - Street 1:643 IH 45 S
Mailing Address - Street 2:
Mailing Address - City:HUNTSVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:77340-6434
Mailing Address - Country:US
Mailing Address - Phone:936-291-3200
Mailing Address - Fax:936-291-9061
Practice Address - Street 1:643 IH 45 S
Practice Address - Street 2:
Practice Address - City:HUNTSVILLE
Practice Address - State:TX
Practice Address - Zip Code:77340-6434
Practice Address - Country:US
Practice Address - Phone:936-291-3200
Practice Address - Fax:936-291-9061
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-07
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX007171261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXASC084Medicare ID - Type Unspecified