Basic Information
| Provider Information | |||||||||
| NPI: | 1770566218 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTH BAY SURGICAL GROUP PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4020 STATE ROAD 674 | ||||||||
| Address2: | SUITE 19 | ||||||||
| City: | SUN CITY CENTER | ||||||||
| State: | FL | ||||||||
| PostalCode: | 335735285 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8138908004 | ||||||||
| FaxNumber: | 8132909691 | ||||||||
| Practice Location | |||||||||
| Address1: | 4020 STATE ROAD 674 | ||||||||
| Address2: | SUITE 19 | ||||||||
| City: | SUN CITY CENTER | ||||||||
| State: | FL | ||||||||
| PostalCode: | 335735285 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8138908004 | ||||||||
| FaxNumber: | 8132909691 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/29/2005 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | GOLDSBERRY | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | T | ||||||||
| AuthorizedOfficialTitleorPosition: | PHYSICIAN | ||||||||
| AuthorizedOfficialTelephone: | 8138908004 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | ME62723 | FL | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
No ID Information.