Provider Demographics
NPI:1033243274
Name:ST. PETERSBURG GENERAL SURGERY LLC
Entity Type:Organization
Organization Name:ST. PETERSBURG GENERAL SURGERY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP
Authorized Official - Prefix:
Authorized Official - First Name:GARY
Authorized Official - Middle Name:
Authorized Official - Last Name:DUNCAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:561-548-1089
Mailing Address - Street 1:3 MARYLAND FARMS
Mailing Address - Street 2:SUITE 250
Mailing Address - City:BRENTWOOD
Mailing Address - State:TN
Mailing Address - Zip Code:37027-5005
Mailing Address - Country:US
Mailing Address - Phone:800-661-3365
Mailing Address - Fax:866-689-4661
Practice Address - Street 1:6450 38TH AVE N
Practice Address - Street 2:SUITE 410
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33710-1645
Practice Address - Country:US
Practice Address - Phone:727-344-4200
Practice Address - Fax:727-344-4221
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-16
Last Update Date:2008-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLAF211Medicare PIN
FLDN0917Medicare PIN