Provider Demographics
NPI:1962713537
Name:PAVILION SURGICAL ASSOCIATES, LLC
Entity type:Organization
Organization Name:PAVILION SURGICAL ASSOCIATES, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:RENEE
Authorized Official - Middle Name:
Authorized Official - Last Name:TAYLOR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-787-6957
Mailing Address - Street 1:4181 HOSPITAL DR NE
Mailing Address - Street 2:SUITE 303
Mailing Address - City:COVINGTON
Mailing Address - State:GA
Mailing Address - Zip Code:30014-2541
Mailing Address - Country:US
Mailing Address - Phone:770-787-6957
Mailing Address - Fax:770-784-0381
Practice Address - Street 1:4181 HOSPITAL DR NE
Practice Address - Street 2:SUITE 303
Practice Address - City:COVINGTON
Practice Address - State:GA
Practice Address - Zip Code:30014-2541
Practice Address - Country:US
Practice Address - Phone:770-787-6957
Practice Address - Fax:770-784-0381
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NEWTON HEALTH SYSTEM, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-06-29
Last Update Date:2015-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty