Provider Demographics
NPI:1962520049
Name:ODESSA SURGICAL ASSOCIATES PA
Entity type:Organization
Organization Name:ODESSA SURGICAL ASSOCIATES PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TERRY
Authorized Official - Middle Name:
Authorized Official - Last Name:UNRUH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:432-550-4200
Mailing Address - Street 1:4222 WENDOVER AVE STE 800
Mailing Address - Street 2:
Mailing Address - City:ODESSA
Mailing Address - State:TX
Mailing Address - Zip Code:79762-5915
Mailing Address - Country:US
Mailing Address - Phone:432-550-4200
Mailing Address - Fax:432-366-3311
Practice Address - Street 1:4222 WENDOVER AVE STE 800
Practice Address - Street 2:
Practice Address - City:ODESSA
Practice Address - State:TX
Practice Address - Zip Code:79762-5915
Practice Address - Country:US
Practice Address - Phone:432-550-4200
Practice Address - Fax:432-366-3311
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ODESSA SURGICAL ASSOCIATES PA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-03-27
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX=========Medicare UPIN