Provider Demographics
NPI:1114410214
Name:SURGICAL CONSULTING GROUP PA
Entity Type:Organization
Organization Name:SURGICAL CONSULTING GROUP PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:T
Authorized Official - Last Name:RIDEOUT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:207-240-3362
Mailing Address - Street 1:PO BOX 511644
Mailing Address - Street 2:
Mailing Address - City:PUNTA GORDA
Mailing Address - State:FL
Mailing Address - Zip Code:33951-1644
Mailing Address - Country:US
Mailing Address - Phone:207-240-3362
Mailing Address - Fax:
Practice Address - Street 1:3050 CHAMPION RING RD
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33905-5599
Practice Address - Country:US
Practice Address - Phone:941-621-6577
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-06-13
Last Update Date:2021-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME129811208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL102201400Medicaid