Provider Demographics
NPI:1336181742
Name:PROMENADES SURGERY CENTER LLC
Entity type:Organization
Organization Name:PROMENADES SURGERY CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:ISSA
Authorized Official - Middle Name:F
Authorized Official - Last Name:BAROUDI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:941-627-5155
Mailing Address - Street 1:3222 TAMIAMI TRL
Mailing Address - Street 2:
Mailing Address - City:PORT CHARLOTTE
Mailing Address - State:FL
Mailing Address - Zip Code:33952-8048
Mailing Address - Country:US
Mailing Address - Phone:941-627-5155
Mailing Address - Fax:
Practice Address - Street 1:3222 TAMIAMI TRL
Practice Address - Street 2:
Practice Address - City:PORT CHARLOTTE
Practice Address - State:FL
Practice Address - Zip Code:33952-8048
Practice Address - Country:US
Practice Address - Phone:941-627-5155
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-11
Last Update Date:2013-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1149261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLF1376Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER