Provider Demographics
NPI:1609940899
Name:2096 EAST OCEAN BOULEVARD, LC
Entity Type:Organization
Organization Name:2096 EAST OCEAN BOULEVARD, LC
Other - Org Name:SURGERY CENTER OF STUART
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:BARBARA
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:TIDWELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:772-223-0174
Mailing Address - Street 1:2096 SE OCEAN BLVD
Mailing Address - Street 2:
Mailing Address - City:STUART
Mailing Address - State:FL
Mailing Address - Zip Code:34996-3304
Mailing Address - Country:US
Mailing Address - Phone:772-223-0174
Mailing Address - Fax:772-223-0558
Practice Address - Street 1:2096 SE OCEAN BLVD
Practice Address - Street 2:
Practice Address - City:STUART
Practice Address - State:FL
Practice Address - Zip Code:34996-3304
Practice Address - Country:US
Practice Address - Phone:772-223-0174
Practice Address - Fax:772-223-0558
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-20
Last Update Date:2012-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL901261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL0097410006OtherCIGNA
FL079144000Medicaid
FL490004057OtherRAILROAD MEDICARE
FL61DOtherBCBS
FL079144000Medicaid