Provider Demographics
NPI:1992728810
Name:SPECIALISTS IN UROLOGY SURGERY CENTER, LLC
Entity type:Organization
Organization Name:SPECIALISTS IN UROLOGY SURGERY CENTER, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICER
Authorized Official - Prefix:MRS
Authorized Official - First Name:LEA
Authorized Official - Middle Name:
Authorized Official - Last Name:HARBOR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:205-545-2572
Mailing Address - Street 1:28930 TRAILS EDGE BOULEVARD
Mailing Address - Street 2:
Mailing Address - City:BONITA SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:34134
Mailing Address - Country:US
Mailing Address - Phone:239-231-7041
Mailing Address - Fax:844-857-1822
Practice Address - Street 1:28930 TRAILS EDGE BOULEVARD
Practice Address - Street 2:
Practice Address - City:BONITA SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:34134
Practice Address - Country:US
Practice Address - Phone:239-231-7041
Practice Address - Fax:844-857-1822
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SPECIALISTS IN UROLOGY SURGERY CENTER, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-07-25
Last Update Date:2016-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1177261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL076522800Medicaid
FLP00085604Medicare PIN
FLF1480Medicare PIN
FL076522800Medicaid