Provider Demographics
NPI:1275667057
Name:TRAUMA & SPECIALTY SURGERY INSTITUTE, LLC
Entity Type:Organization
Organization Name:TRAUMA & SPECIALTY SURGERY INSTITUTE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:LORI
Authorized Official - Middle Name:
Authorized Official - Last Name:JAZAREVIC
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:772-233-6166
Mailing Address - Street 1:1076 FERN TRL
Mailing Address - Street 2:
Mailing Address - City:WAYNESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28786-9706
Mailing Address - Country:US
Mailing Address - Phone:772-233-6166
Mailing Address - Fax:
Practice Address - Street 1:311 N CLYDE MORRIS BLVD STE 440
Practice Address - Street 2:
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32114-2757
Practice Address - Country:US
Practice Address - Phone:386-252-0688
Practice Address - Fax:386-675-6401
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-15
Last Update Date:2021-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 65570208600000X
FLME655702086S0102X, 2086S0127X, 2086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
No2086S0102XAllopathic & Osteopathic PhysiciansSurgerySurgical Critical CareGroup - Multi-Specialty
No2086S0127XAllopathic & Osteopathic PhysiciansSurgeryTrauma SurgeryGroup - Multi-Specialty
No2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLME 65570OtherMEDICAL LICENSE
FLAC367Medicare PIN