Provider Demographics
NPI:1801028246
Name:SURFSIDE FAMILY MEDICINE LLC
Entity Type:Organization
Organization Name:SURFSIDE FAMILY MEDICINE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:OLGA
Authorized Official - Middle Name:DORJIMA
Authorized Official - Last Name:EMGUSHOV
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:321-799-2554
Mailing Address - Street 1:3000 N ATLANTIC AVE STE 108
Mailing Address - Street 2:
Mailing Address - City:COCOA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32931-5029
Mailing Address - Country:US
Mailing Address - Phone:321-799-2554
Mailing Address - Fax:321-799-4750
Practice Address - Street 1:3000 N ATLANTIC AVE STE 108
Practice Address - Street 2:
Practice Address - City:COCOA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32931-5029
Practice Address - Country:US
Practice Address - Phone:321-799-2554
Practice Address - Fax:321-799-4750
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-19
Last Update Date:2009-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME94076261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care