Provider Demographics
NPI:1104868413
Name:GATEWAY SURGICAL GROUP LLC
Entity Type:Organization
Organization Name:GATEWAY SURGICAL GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP
Authorized Official - Prefix:
Authorized Official - First Name:MICKEY
Authorized Official - Middle Name:
Authorized Official - Last Name:PICKLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:386-755-6682
Mailing Address - Street 1:3140 NW MEDICAL CENTER LN
Mailing Address - Street 2:SUITE 120
Mailing Address - City:LAKE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32055-4717
Mailing Address - Country:US
Mailing Address - Phone:386-755-6682
Mailing Address - Fax:386-755-6796
Practice Address - Street 1:3140 NW MEDICAL CENTER LN
Practice Address - Street 2:SUITE 120
Practice Address - City:LAKE CITY
Practice Address - State:FL
Practice Address - Zip Code:32055-4717
Practice Address - Country:US
Practice Address - Phone:386-755-6682
Practice Address - Fax:386-755-6796
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-12
Last Update Date:2008-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL94830OtherBCBS OF FL
FL94830OtherBCBS OF FL
FLK7414Medicare PIN