Provider Demographics
NPI:1033223367
Name:SOUTHEASTERN OUTPATIENT SURGERY CENTER LLC
Entity Type:Organization
Organization Name:SOUTHEASTERN OUTPATIENT SURGERY CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BEN
Authorized Official - Middle Name:J
Authorized Official - Last Name:KIRBO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:850-219-2000
Mailing Address - Street 1:2030 FLEISCHMANN RD
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32308
Mailing Address - Country:US
Mailing Address - Phone:850-219-2000
Mailing Address - Fax:850-877-2138
Practice Address - Street 1:2030 FLEISCHMANN RD
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32308
Practice Address - Country:US
Practice Address - Phone:850-219-2000
Practice Address - Fax:850-877-2138
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-17
Last Update Date:2014-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1216261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical