Provider Demographics
NPI:1114447521
Name:MINIMALLY INVASIVE SURGICAL SPECIALISTS
Entity Type:Organization
Organization Name:MINIMALLY INVASIVE SURGICAL SPECIALISTS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:TIFFANI
Authorized Official - Middle Name:
Authorized Official - Last Name:SHELTON
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:727-274-1330
Mailing Address - Street 1:8142 BELLARUS WAY STE 101
Mailing Address - Street 2:
Mailing Address - City:TRINITY
Mailing Address - State:FL
Mailing Address - Zip Code:34655-1799
Mailing Address - Country:US
Mailing Address - Phone:727-274-1330
Mailing Address - Fax:855-274-0039
Practice Address - Street 1:8142 BELLARUS WAY STE 101
Practice Address - Street 2:
Practice Address - City:TRINITY
Practice Address - State:FL
Practice Address - Zip Code:34655-1799
Practice Address - Country:US
Practice Address - Phone:727-274-1330
Practice Address - Fax:855-274-0039
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-06-27
Last Update Date:2019-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS13410208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty