1770588584 NPI number — PHYSICIANS SURGERY CENTER LLC

Table of content: (NPI 1770588584)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770588584 NPI number — PHYSICIANS SURGERY CENTER LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PHYSICIANS SURGERY CENTER 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:
6
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:
1770588584
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/10/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 715803
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CINCINNATI
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
45271-5803
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
239-788-0604
Provider Business Mailing Address Fax Number:
239-230-0041

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4035 EVANS AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FT MYERS
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33901-9308
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
239-788-0604
Provider Business Practice Location Address Fax Number:
239-230-0041
Provider Enumeration Date:
06/17/2005

Additional Information

Authorized Official

Authorized Official Last Name:
HENSLEY-MARTIN
Authorized Official First Name:
REBEKAH
Authorized Official Middle Name:
Authorized Official Title or Position:
OFFICER AND AUTHORIZED OFFICIAL
Authorized Official Telephone Number:
757-846-6946

Provider Taxonomy Codes

  • Taxonomy code: 261QA1903X , with the licence number:  815 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 062967700 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 116236200 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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