Provider Demographics
NPI:1639105455
Name:ENDOSURG OUTPATIENT CENTER LLC
Entity Type:Organization
Organization Name:ENDOSURG OUTPATIENT CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:
Authorized Official - First Name:LILY
Authorized Official - Middle Name:
Authorized Official - Last Name:TRAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:352-323-8868
Mailing Address - Street 1:13838 N US HIGHWAY 441
Mailing Address - Street 2:
Mailing Address - City:LADY LAKE
Mailing Address - State:FL
Mailing Address - Zip Code:32159-8904
Mailing Address - Country:US
Mailing Address - Phone:352-753-1612
Mailing Address - Fax:352-728-5497
Practice Address - Street 1:13838 N US HIGHWAY 441
Practice Address - Street 2:
Practice Address - City:LADY LAKE
Practice Address - State:FL
Practice Address - Zip Code:32159-8904
Practice Address - Country:US
Practice Address - Phone:352-753-1612
Practice Address - Fax:352-728-5497
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-23
Last Update Date:2014-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1115261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLF1346Medicare ID - Type Unspecified