Provider Demographics
NPI:1164719209
Name:SURGICAL SPECIALISTS OF ST LUCIE
Entity Type:Organization
Organization Name:SURGICAL SPECIALISTS OF ST LUCIE
Other - Org Name:BLUE WATER SURGERY CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGING DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ALLEN
Authorized Official - Middle Name:
Authorized Official - Last Name:LICHT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:954-906-9536
Mailing Address - Street 1:12350 NW 39TH ST STE 200
Mailing Address - Street 2:
Mailing Address - City:CORAL SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:33065-2414
Mailing Address - Country:US
Mailing Address - Phone:954-248-3422
Mailing Address - Fax:
Practice Address - Street 1:6830 S US HIGHWAY 1
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34952-1410
Practice Address - Country:US
Practice Address - Phone:772-873-6700
Practice Address - Fax:772-465-5499
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-08
Last Update Date:2023-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1570261QA1903X, 261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL006594000Medicaid
FL10C0001570Medicare PIN