Basic Information
| Provider Information | |||||||||
| NPI: | 1740395748 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SPECIALTYCARE SURGICAL ASSIST, LLC | ||||||||
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| OtherOrganizationName: | SURGICAL ASSIST, LLC | ||||||||
| OtherOrganizationType: | 4 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3 MARYLAND FARMS STE 200 | ||||||||
| Address2: | |||||||||
| City: | BRENTWOOD | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370275005 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6153455400 | ||||||||
| FaxNumber: | 6153455405 | ||||||||
| Practice Location | |||||||||
| Address1: | 2240 W WOOLBRIGHT RD STE 210 | ||||||||
| Address2: | |||||||||
| City: | BOYNTON BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334266363 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8003484565 | ||||||||
| FaxNumber: | 6153455405 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/20/2006 | ||||||||
| LastUpdateDate: | 12/20/2018 | ||||||||
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| AuthorizedOfficialLastName: | GRAY | ||||||||
| AuthorizedOfficialFirstName: | JEFFREY | ||||||||
| AuthorizedOfficialMiddleName: | T | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO & TREASURER | ||||||||
| AuthorizedOfficialTelephone: | 6153455550 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AS0400X | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
ID Information
| ID | Type | State | Issuer | Description | 292913900 | 05 | FL | MEDICAID |