Provider Demographics
NPI:1487353330
Name:SURGICAL SERVICES LLC
Entity type:Organization
Organization Name:SURGICAL SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER
Authorized Official - Prefix:DR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:DALE
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD, SAC
Authorized Official - Phone:228-304-9436
Mailing Address - Street 1:15520 DANIEL BLVD # 310
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39503-4735
Mailing Address - Country:US
Mailing Address - Phone:228-304-9436
Mailing Address - Fax:
Practice Address - Street 1:4500 13TH ST
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39501-2515
Practice Address - Country:US
Practice Address - Phone:228-867-4000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-03-01
Last Update Date:2023-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302F00000XManaged Care OrganizationsExclusive Provider Organization