Provider Demographics
NPI:1336100189
Name:ST MICHAELS SURGERY CENTER INC.
Entity Type:Organization
Organization Name:ST MICHAELS SURGERY CENTER INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:L
Authorized Official - Last Name:MICHAELOS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:727-585-2200
Mailing Address - Street 1:1018 W BAY DR
Mailing Address - Street 2:
Mailing Address - City:LARGO
Mailing Address - State:FL
Mailing Address - Zip Code:33770-3225
Mailing Address - Country:US
Mailing Address - Phone:727-585-2200
Mailing Address - Fax:727-584-9239
Practice Address - Street 1:1018 W BAY DR
Practice Address - Street 2:
Practice Address - City:LARGO
Practice Address - State:FL
Practice Address - Zip Code:33770-3225
Practice Address - Country:US
Practice Address - Phone:727-585-2200
Practice Address - Fax:727-584-9239
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-31
Last Update Date:2012-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1118261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL070826700Medicaid
FL69KOtherBCBS PROVIDER ID
FL50101269OtherAETNA PROVIDER ID
FL69KOtherBCBS PROVIDER ID
FL070826700Medicaid