Provider Demographics
NPI:1790801215
Name:CENTER FOR BREAST CARE & OUTPATIENT SURGERY
Entity Type:Organization
Organization Name:CENTER FOR BREAST CARE & OUTPATIENT SURGERY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:DISNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:352-596-0184
Mailing Address - Street 1:5327 COMMERCIAL WAY STE D119
Mailing Address - Street 2:
Mailing Address - City:SPRING HILL
Mailing Address - State:FL
Mailing Address - Zip Code:34606-1420
Mailing Address - Country:US
Mailing Address - Phone:352-596-0184
Mailing Address - Fax:352-596-6559
Practice Address - Street 1:5327 COMMERCIAL WAY STE D119
Practice Address - Street 2:
Practice Address - City:SPRING HILL
Practice Address - State:FL
Practice Address - Zip Code:34606-1420
Practice Address - Country:US
Practice Address - Phone:352-596-0184
Practice Address - Fax:352-596-6559
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME38557208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLD55979Medicare UPIN
FLK7368Medicare ID - Type UnspecifiedMEDICARE GROUP NUMBER