Provider Demographics
NPI:1427237031
Name:ROCKDALE SURGICAL CENTER
Entity type:Organization
Organization Name:ROCKDALE SURGICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:
Authorized Official - First Name:LYNWOOD
Authorized Official - Middle Name:
Authorized Official - Last Name:CLEAVELAND
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-760-0182
Mailing Address - Street 1:4122 TATE ST NE
Mailing Address - Street 2:
Mailing Address - City:COVINGTON
Mailing Address - State:GA
Mailing Address - Zip Code:30014-2551
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4122 TATE ST NE
Practice Address - Street 2:
Practice Address - City:COVINGTON
Practice Address - State:GA
Practice Address - Zip Code:30014-2551
Practice Address - Country:US
Practice Address - Phone:770-760-0182
Practice Address - Fax:770-483-3291
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ROCKDALE SURGICAL CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-10-31
Last Update Date:2019-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA023925208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00399506AMedicaid
0858210001Medicare NSC
GA34BDBTRMedicare UPIN