Provider Demographics
NPI:1467101907
Name:PEACE RIVER SURGERY CENTER
Entity Type:Organization
Organization Name:PEACE RIVER SURGERY CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:NICOLAI
Authorized Official - Middle Name:
Authorized Official - Last Name:MEJEVOI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:941-629-5356
Mailing Address - Street 1:4130 TAMIAMI TRL UNIT 301
Mailing Address - Street 2:
Mailing Address - City:PORT CHARLOTTE
Mailing Address - State:FL
Mailing Address - Zip Code:33952-9207
Mailing Address - Country:US
Mailing Address - Phone:941-629-5356
Mailing Address - Fax:941-629-4987
Practice Address - Street 1:4130 TAMIAMI TRL UNIT 301
Practice Address - Street 2:
Practice Address - City:PORT CHARLOTTE
Practice Address - State:FL
Practice Address - Zip Code:33952-9207
Practice Address - Country:US
Practice Address - Phone:941-629-5356
Practice Address - Fax:941-629-4987
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-03-22
Last Update Date:2023-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory SurgicalGroup - Single Specialty