Provider Demographics
NPI:1760622526
Name:SPACE COAST SURGERY LLC
Entity Type:Organization
Organization Name:SPACE COAST SURGERY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSCIAN/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHINMAY
Authorized Official - Middle Name:S
Authorized Official - Last Name:MAJMUNDAR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:321-242-7060
Mailing Address - Street 1:8255 N WICKHAM RD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32940-8202
Mailing Address - Country:US
Mailing Address - Phone:321-242-7060
Mailing Address - Fax:321-242-6050
Practice Address - Street 1:8255 N WICKHAM RD
Practice Address - Street 2:SUITE 102
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32940-8202
Practice Address - Country:US
Practice Address - Phone:321-242-7060
Practice Address - Fax:321-242-6050
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-05
Last Update Date:2014-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 96869208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty