Provider Demographics
NPI:1366978991
Name:OLYMPIAN SURGICAL ASSISTANTS
Entity type:Organization
Organization Name:OLYMPIAN SURGICAL ASSISTANTS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:BRANDON
Authorized Official - Middle Name:VIRDELL
Authorized Official - Last Name:KING
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:678-517-3428
Mailing Address - Street 1:PO BOX 81
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30061-0081
Mailing Address - Country:US
Mailing Address - Phone:678-517-3428
Mailing Address - Fax:770-485-1534
Practice Address - Street 1:55 ATLANTA ST SE STE 204
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30060-1977
Practice Address - Country:US
Practice Address - Phone:678-517-3428
Practice Address - Fax:770-485-1534
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-05-02
Last Update Date:2021-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA051517853208600000X
363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgicalGroup - Multi-Specialty
No208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty