Provider Demographics
NPI:1558420083
Name:JOHN W ROYALTY DO PA
Entity Type:Organization
Organization Name:JOHN W ROYALTY DO PA
Other - Org Name:SEVEN RIVERS VASCULAR
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:WAYNE
Authorized Official - Last Name:ROYALTY
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:352-563-5488
Mailing Address - Street 1:3402 N LECANTO HWY
Mailing Address - Street 2:SUITE C
Mailing Address - City:BEVERLY HILLS
Mailing Address - State:FL
Mailing Address - Zip Code:34465-3570
Mailing Address - Country:US
Mailing Address - Phone:352-563-5488
Mailing Address - Fax:352-563-6328
Practice Address - Street 1:3402 N LECANTO HWY
Practice Address - Street 2:SUITE C
Practice Address - City:BEVERLY HILLS
Practice Address - State:FL
Practice Address - Zip Code:34465-3570
Practice Address - Country:US
Practice Address - Phone:352-563-5488
Practice Address - Fax:352-563-6328
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-08
Last Update Date:2015-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)Group - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL34171OtherBLUE CROSS BLUE SHIELD
K2310Medicare ID - Type Unspecified