1619792215 NPI number — CCRM FLORIDA SURGERY LLC

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 1619792215 NPI number — CCRM FLORIDA SURGERY LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CCRM FLORIDA SURGERY LLC
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:
1619792215
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/24/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9380 STATION ST STE 425
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LONE TREE
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
80124-6832
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
19505 BISCAYNE BLVD STE 2230
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MIAMI
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33180-3644
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
305-526-4530
Provider Business Practice Location Address Fax Number:
833-983-0045
Provider Enumeration Date:
11/19/2024

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
RAVECH
Authorized Official First Name:
DIANE
Authorized Official Middle Name:
JEAN
Authorized Official Title or Position:
CHIEF MANAGED CARE OFFICER
Authorized Official Telephone Number:
860-305-6640

Provider Taxonomy Codes

  • Taxonomy code: 261QA1903X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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