Provider Demographics
NPI:1710071519
Name:BRANDON AMBULATORY SURGERY CENTER LC
Entity Type:Organization
Organization Name:BRANDON AMBULATORY SURGERY CENTER LC
Other - Org Name:EAST HILLSBOROUGH SURGERY CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF ADMINISTRATIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:PAULA
Authorized Official - Middle Name:
Authorized Official - Last Name:RUSSO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:813-571-7088
Mailing Address - Street 1:514 EICHENFELD DRIVE
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:FL
Mailing Address - Zip Code:33511
Mailing Address - Country:US
Mailing Address - Phone:813-571-7088
Mailing Address - Fax:813-571-7099
Practice Address - Street 1:514 EICHENFELD DRIVE
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33511
Practice Address - Country:US
Practice Address - Phone:813-571-7088
Practice Address - Fax:813-571-7099
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-03
Last Update Date:2019-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QA1903X
FL1228261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL076908800Medicaid
FLF1445Medicare ID - Type UnspecifiedMEDICARE FACILITY NUMBER