1053366674 NPI number — TREASURE COAST SURGICAL GROUP

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053366674 NPI number — TREASURE COAST SURGICAL GROUP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TREASURE COAST SURGICAL GROUP
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1053366674
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/07/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2221 SE OCEAN BLVD
Provider Second Line Business Mailing Address:
SUITE 200
Provider Business Mailing Address City Name:
STUART
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
34996-3341
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
772-219-4026
Provider Business Mailing Address Fax Number:
772-219-8207

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2221 SE OCEAN BLVD
Provider Second Line Business Practice Location Address:
SUITE 200
Provider Business Practice Location Address City Name:
STUART
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34996-3341
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
772-219-4026
Provider Business Practice Location Address Fax Number:
772-219-8207
Provider Enumeration Date:
05/23/2006

Additional Information

Authorized Official

Authorized Official Last Name:
KLEABIR
Authorized Official First Name:
DAWN
Authorized Official Middle Name:
MICHELLE
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
772-219-4026

Provider Taxonomy Codes

  • Taxonomy code: 174400000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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