Provider Demographics
NPI:1386882587
Name:BAYLOR SURGICARE AT GRANBURY LLC
Entity type:Organization
Organization Name:BAYLOR SURGICARE AT GRANBURY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:DONITA
Authorized Official - Middle Name:
Authorized Official - Last Name:FLEMING
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:202-815-3665
Mailing Address - Street 1:1717 PALUXY RD
Mailing Address - Street 2:
Mailing Address - City:GRANBURY
Mailing Address - State:TX
Mailing Address - Zip Code:76048-5667
Mailing Address - Country:US
Mailing Address - Phone:817-579-8863
Mailing Address - Fax:817-579-8872
Practice Address - Street 1:1717 PALUXY RD
Practice Address - Street 2:
Practice Address - City:GRANBURY
Practice Address - State:TX
Practice Address - Zip Code:76048-5667
Practice Address - Country:US
Practice Address - Phone:817-579-8863
Practice Address - Fax:817-579-8872
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-26
Last Update Date:2024-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX130006261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXP00724957OtherRAILROAD MEDICARE
TX45C0001471Medicare Oscar/Certification
TXASC376Medicare PIN