Provider Demographics
NPI:1689624793
Name:SURGERY CENTER OF SOUTHWEST FLORIDA INC
Entity Type:Organization
Organization Name:SURGERY CENTER OF SOUTHWEST FLORIDA INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:R
Authorized Official - Last Name:BRETTON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:239-939-4758
Mailing Address - Street 1:12631 WHITEHALL DR
Mailing Address - Street 2:
Mailing Address - City:FT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33907-3626
Mailing Address - Country:US
Mailing Address - Phone:239-939-4758
Mailing Address - Fax:239-479-7874
Practice Address - Street 1:12631 WHITEHALL DR
Practice Address - Street 2:
Practice Address - City:FT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33907-3626
Practice Address - Country:US
Practice Address - Phone:239-939-4758
Practice Address - Fax:239-479-7874
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-11
Last Update Date:2012-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1125261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL075319000Medicaid
FLF1354Medicare ID - Type Unspecified