Provider Demographics
NPI:1366499923
Name:TAMPA BAY CENTER FOR SPECIALIZED SURGERY INC
Entity Type:Organization
Organization Name:TAMPA BAY CENTER FOR SPECIALIZED SURGERY INC
Other - Org Name:CENTER FOR SPECIALIZED SURGERY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:FACILITY ADMINISTATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:MARY
Authorized Official - Middle Name:ELIZABETH
Authorized Official - Last Name:DYKEMA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:813-874-2040
Mailing Address - Street 1:PO BOX 152199
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33684-2199
Mailing Address - Country:US
Mailing Address - Phone:813-874-2040
Mailing Address - Fax:813-876-3438
Practice Address - Street 1:2808 W DR MARTIN LUTHER KING JR BLVD
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33607-6306
Practice Address - Country:US
Practice Address - Phone:813-874-2040
Practice Address - Fax:813-876-3438
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-28
Last Update Date:2013-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL912261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL2173001OtherAETNA
OH593535954200OtherBWC
KY162422500OtherACS
FL912OtherSTATE OF FLORIDA
OH593535954200OtherBWC