Provider Demographics
NPI:1790761393
Name:ST. LUCIE SURGICAL CENTER, P.A.
Entity Type:Organization
Organization Name:ST. LUCIE SURGICAL CENTER, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ANJANAYA
Authorized Official - Middle Name:PRASAD
Authorized Official - Last Name:KORLIPARA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:772-429-5201
Mailing Address - Street 1:1300 N LAWNWOOD CIR
Mailing Address - Street 2:
Mailing Address - City:FORT PIERCE
Mailing Address - State:FL
Mailing Address - Zip Code:34950-4884
Mailing Address - Country:US
Mailing Address - Phone:772-429-5201
Mailing Address - Fax:772-429-5204
Practice Address - Street 1:1300 N LAWNWOOD CIR
Practice Address - Street 2:
Practice Address - City:FORT PIERCE
Practice Address - State:FL
Practice Address - Zip Code:34950-4884
Practice Address - Country:US
Practice Address - Phone:772-429-5201
Practice Address - Fax:772-429-5204
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-16
Last Update Date:2012-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1107261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL070735000Medicaid
FL070735000Medicaid