Basic Information
Provider Information | |||||||||
NPI: | 1790752863 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | INVERNESS SURGICAL ASSOCIATION P A | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 403 W HIGHLAND BLVD | ||||||||
Address2: |   | ||||||||
City: | INVERNESS | ||||||||
State: | FL | ||||||||
PostalCode: | 344524717 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3527263646 | ||||||||
FaxNumber: | 3527260079 | ||||||||
Practice Location | |||||||||
Address1: | 403 W HIGHLAND BLVD | ||||||||
Address2: |   | ||||||||
City: | INVERNESS | ||||||||
State: | FL | ||||||||
PostalCode: | 344524717 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3527263646 | ||||||||
FaxNumber: | 3527260079 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/07/2006 | ||||||||
LastUpdateDate: | 01/25/2011 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | FERNANDEZ | ||||||||
AuthorizedOfficialFirstName: | MARC | ||||||||
AuthorizedOfficialMiddleName: | E | ||||||||
AuthorizedOfficialTitleorPosition: | OFFICER/SECRETARY | ||||||||
AuthorizedOfficialTelephone: | 3527263646 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | M.D. | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 80110207817 | FL | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |   |
ID Information
ID | Type | State | Issuer | Description | 38905 | 01 | FL | BCBS GROUP | OTHER | 258062400 | 05 | FL |   | MEDICAID |