Provider Demographics
NPI:1033103437
Name:SURGICAL SPECIALISTS OF SOUTHWEST FLORIDA P.A.
Entity Type:Organization
Organization Name:SURGICAL SPECIALISTS OF SOUTHWEST FLORIDA P.A.
Other - Org Name:SURGICAL SPECIALISTS OF SOUTHWEST FLORIDA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GORDON
Authorized Official - Middle Name:D
Authorized Official - Last Name:BURTCH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:239-936-8555
Mailing Address - Street 1:6821 PALISADES PARK CT
Mailing Address - Street 2:SUITE 1
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33912-7131
Mailing Address - Country:US
Mailing Address - Phone:239-936-8555
Mailing Address - Fax:239-936-5611
Practice Address - Street 1:6821 PALISADES PARK CT
Practice Address - Street 2:SUITE 1
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33912-7131
Practice Address - Country:US
Practice Address - Phone:239-936-8555
Practice Address - Fax:239-936-5611
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-31
Last Update Date:2014-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Multi-Specialty
No208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL052343700Medicaid
FL052343700Medicaid