Provider Demographics
NPI:1558618116
Name:TAVARES SURGERY LLC
Entity Type:Organization
Organization Name:TAVARES SURGERY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:SOUNDARAPANDIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:BASKAR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:352-636-3652
Mailing Address - Street 1:1878 MAYO DR
Mailing Address - Street 2:
Mailing Address - City:TAVARES
Mailing Address - State:FL
Mailing Address - Zip Code:32778-4308
Mailing Address - Country:US
Mailing Address - Phone:352-508-5401
Mailing Address - Fax:877-535-4708
Practice Address - Street 1:1878 MAYO DR
Practice Address - Street 2:
Practice Address - City:TAVARES
Practice Address - State:FL
Practice Address - Zip Code:32778-4308
Practice Address - Country:US
Practice Address - Phone:352-508-5401
Practice Address - Fax:877-535-4708
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-13
Last Update Date:2014-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLF1575Medicare PIN