Provider Demographics
NPI:1235393356
Name:PHYSICIANS OUTPATIENT SURGERY CENTER LLC
Entity Type:Organization
Organization Name:PHYSICIANS OUTPATIENT SURGERY CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:DISSETTE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:954-958-0635
Mailing Address - Street 1:1000 NE 56TH ST
Mailing Address - Street 2:
Mailing Address - City:FT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33334-4149
Mailing Address - Country:US
Mailing Address - Phone:954-958-0635
Mailing Address - Fax:954-489-2846
Practice Address - Street 1:1000 NE 56TH ST
Practice Address - Street 2:
Practice Address - City:FT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33334-4149
Practice Address - Country:US
Practice Address - Phone:954-958-0635
Practice Address - Fax:954-489-2846
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-17
Last Update Date:2008-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
F1497Medicare PIN