Anniston General Surgery Center, P.C.

Contacts

Phone	+1 256-240-9660
Fax	2562409636

Authorized person

Name	DR. CLIFFORD P BLACK JR.
Role	PRESIDENT
Phone	2562409660

Taxonomy

Taxonomy Code	208600000X - Surgery Physician
Is Primary	Yes

File	View Page
Three-digit plan number (PN)	001
Effective date of plan	1999-01-01
Business code	621111
Sponsor’s telephone number	2562409660
Plan sponsor’s address	1901 LEIGHTON AVENUE, ANNISTON, AL, 36207

Signature of

Role	Plan administrator
Date	2017-12-14
Name of individual signing	CLIFFORD BLACK

File	View Page
Three-digit plan number (PN)	001
Effective date of plan	1999-01-01
Business code	621111
Sponsor’s telephone number	2562409660
Plan sponsor’s address	1901 LEIGHTON AVENUE, ANNISTON, AL, 36207

Signature of

Role	Plan administrator
Date	2017-04-17
Name of individual signing	CLIFFORD BLACK

File	View Page
Three-digit plan number (PN)	001
Effective date of plan	1999-01-01
Business code	621111
Sponsor’s telephone number	2562409660
Plan sponsor’s address	1901 LEIGHTON AVENUE, ANNISTON, AL, 36207

Signature of

Role	Plan administrator
Date	2016-04-15
Name of individual signing	CLIFFORD BLACK

File	View Page
Three-digit plan number (PN)	001
Effective date of plan	1999-01-01
Business code	621111
Sponsor’s telephone number	2562409660
Plan sponsor’s address	1901 LEIGHTON AVENUE, ANNISTON, AL, 36207

Signature of

Role	Plan administrator
Date	2015-09-30
Name of individual signing	CLIFFORD BLACK

File	View Page
Three-digit plan number (PN)	001
Effective date of plan	1999-01-01
Business code	621111
Sponsor’s telephone number	2562409660
Plan sponsor’s address	1901 LEIGHTON AVENUE, ANNISTON, AL, 36207

Signature of

Role	Plan administrator
Date	2014-08-27
Name of individual signing	CLIFFORD BLACK