Provider Demographics
NPI:1437184090
Name:SUNSHINE STATE SURGICAL SPECIALISTS PA
Entity Type:Organization
Organization Name:SUNSHINE STATE SURGICAL SPECIALISTS PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:S
Authorized Official - Last Name:BJERKEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:352-742-1300
Mailing Address - Street 1:PO BOX 547
Mailing Address - Street 2:
Mailing Address - City:TAVARES
Mailing Address - State:FL
Mailing Address - Zip Code:32778
Mailing Address - Country:US
Mailing Address - Phone:352-742-1300
Mailing Address - Fax:352-742-1305
Practice Address - Street 1:1879 NIGHTINGALE LANE
Practice Address - Street 2:SUITE B3
Practice Address - City:TAVARES
Practice Address - State:FL
Practice Address - Zip Code:32778
Practice Address - Country:US
Practice Address - Phone:352-742-1300
Practice Address - Fax:352-742-1305
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-12
Last Update Date:2008-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME88645208600000X, 2086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
No2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
E83967Medicare UPIN
FLK8171Medicare ID - Type UnspecifiedGROUP