Provider Demographics
NPI:1760591952
Name:PONTE VEDRA AMBULATORY SURGERY CENTER, LLC
Entity Type:Organization
Organization Name:PONTE VEDRA AMBULATORY SURGERY CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING EMPLOYEE
Authorized Official - Prefix:
Authorized Official - First Name:ROBIN
Authorized Official - Middle Name:
Authorized Official - Last Name:SOLOMON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-273-6200
Mailing Address - Street 1:209 PONTE VEDRA PARK DRIVE
Mailing Address - Street 2:
Mailing Address - City:PONTE VEDRA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32082-6600
Mailing Address - Country:US
Mailing Address - Phone:904-273-6200
Mailing Address - Fax:904-280-8013
Practice Address - Street 1:209 PONTE VEDRA PARK DRIVE
Practice Address - Street 2:
Practice Address - City:PONTE VEDRA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32082-6600
Practice Address - Country:US
Practice Address - Phone:904-273-6200
Practice Address - Fax:904-280-8013
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-30
Last Update Date:2024-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1156261QA1903X
FL10-C001394261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLF1394Medicare PIN