Provider Demographics
NPI:1679847529
Name:WEST COAST SURGICAL GROUP PLLC
Entity Type:Organization
Organization Name:WEST COAST SURGICAL GROUP PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:DR
Authorized Official - First Name:PAIGE
Authorized Official - Middle Name:KOENIG
Authorized Official - Last Name:PENNEBACKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:941-761-0500
Mailing Address - Street 1:PO BOX 14731
Mailing Address - Street 2:
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34280-4731
Mailing Address - Country:US
Mailing Address - Phone:941-545-4002
Mailing Address - Fax:941-748-6195
Practice Address - Street 1:5953 17TH AVE W
Practice Address - Street 2:
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34209-7836
Practice Address - Country:US
Practice Address - Phone:941-746-8127
Practice Address - Fax:941-746-8127
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-23
Last Update Date:2018-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME62365208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty