Basic Information
| Provider Information | |||||||||
| NPI: | 1982688628 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NORTH FLORIDA SURGICAL ASSOCIATES LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2000 HEALTH PARK DR | ||||||||
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| City: | BRENTWOOD | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370274525 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6153725426 | ||||||||
| FaxNumber: | 8668314898 | ||||||||
| Practice Location | |||||||||
| Address1: | 1121 NW 64TH TER | ||||||||
| Address2: | SUITE B | ||||||||
| City: | GAINESVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 326054243 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3523313583 | ||||||||
| FaxNumber: | 3523313669 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/06/2005 | ||||||||
| LastUpdateDate: | 11/10/2017 | ||||||||
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| AuthorizedOfficialLastName: | RODKEY | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | MARK | ||||||||
| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8505233816 | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208G00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Thoracic Surgery (Cardiothoracic Vascular Surgery) |
ID Information
| ID | Type | State | Issuer | Description | 275341300 | 05 | FL | MEDICAID |