Provider Demographics
NPI:1861755654
Name:SURGEON SERVICES PROFESSIONAL CORPORATION
Entity type:Organization
Organization Name:SURGEON SERVICES PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JASON
Authorized Official - Middle Name:
Authorized Official - Last Name:DIAMOND
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-859-9816
Mailing Address - Street 1:9400 BRIGHTON WAY
Mailing Address - Street 2:PENTHOUSE SUITE
Mailing Address - City:BEVERLY HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:90210-4714
Mailing Address - Country:US
Mailing Address - Phone:310-859-9816
Mailing Address - Fax:310-859-9815
Practice Address - Street 1:9400 BRIGHTON WAY
Practice Address - Street 2:PENTHOUSE
Practice Address - City:BEVERLY HILLS
Practice Address - State:CA
Practice Address - Zip Code:90210-4714
Practice Address - Country:US
Practice Address - Phone:310-859-9816
Practice Address - Fax:310-859-9815
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-18
Last Update Date:2012-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA78700207V00000X, 207X00000X, 207YX0905X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207YX0905XAllopathic & Osteopathic PhysiciansOtolaryngologyOtolaryngology/Facial Plastic SurgeryGroup - Multi-Specialty
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty