Provider Demographics
NPI:1790752863
Name:INVERNESS SURGICAL ASSOCIATION P A
Entity Type:Organization
Organization Name:INVERNESS SURGICAL ASSOCIATION P A
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICER/SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:MARC
Authorized Official - Middle Name:E
Authorized Official - Last Name:FERNANDEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:352-726-3646
Mailing Address - Street 1:403 W HIGHLAND BLVD
Mailing Address - Street 2:
Mailing Address - City:INVERNESS
Mailing Address - State:FL
Mailing Address - Zip Code:34452-4717
Mailing Address - Country:US
Mailing Address - Phone:352-726-3646
Mailing Address - Fax:352-726-0079
Practice Address - Street 1:403 W HIGHLAND BLVD
Practice Address - Street 2:
Practice Address - City:INVERNESS
Practice Address - State:FL
Practice Address - Zip Code:34452-4717
Practice Address - Country:US
Practice Address - Phone:352-726-3646
Practice Address - Fax:352-726-0079
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-07
Last Update Date:2011-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL80110207817174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL38905OtherBCBS GROUP
FL258062400Medicaid
FL38905Medicare ID - Type UnspecifiedGROUP