Provider Demographics
NPI:1073543310
Name:PLASTIC SURGERY CENTER OF LAKE COUNTY
Entity Type:Organization
Organization Name:PLASTIC SURGERY CENTER OF LAKE COUNTY
Other - Org Name:BOSSHARDT & MARZEK PLASTIC SURGERY ASSOCIATES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:VERA
Authorized Official - Middle Name:D
Authorized Official - Last Name:RENFRO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:352-742-0079
Mailing Address - Street 1:1879 NIGHTINGALE LN
Mailing Address - Street 2:A-2
Mailing Address - City:TAVARES
Mailing Address - State:FL
Mailing Address - Zip Code:32778-4363
Mailing Address - Country:US
Mailing Address - Phone:352-742-0079
Mailing Address - Fax:352-742-0059
Practice Address - Street 1:1879 NIGHTINGALE LN
Practice Address - Street 2:A-2
Practice Address - City:TAVARES
Practice Address - State:FL
Practice Address - Zip Code:32778-4363
Practice Address - Country:US
Practice Address - Phone:352-742-0079
Practice Address - Fax:352-742-0059
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-03
Last Update Date:2008-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1049261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL252761801Medicaid
FL6B8OtherBLUE CROSS AND SHIELD FL
FL490003374OtherRAILROAD MEDICARE
FL6B8OtherBLUE CROSS AND SHIELD FL