Provider Demographics
NPI:1811001233
Name:SOUTHERN PINELLAS SURGICAL PA
Entity Type:Organization
Organization Name:SOUTHERN PINELLAS SURGICAL PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:F
Authorized Official - Last Name:FANSLER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:727-584-9500
Mailing Address - Street 1:12955 SEMINOLE BLVD
Mailing Address - Street 2:
Mailing Address - City:LARGO
Mailing Address - State:FL
Mailing Address - Zip Code:33778-2399
Mailing Address - Country:US
Mailing Address - Phone:727-584-9500
Mailing Address - Fax:727-584-9502
Practice Address - Street 1:12955 SEMINOLE BLVD
Practice Address - Street 2:
Practice Address - City:LARGO
Practice Address - State:FL
Practice Address - Zip Code:33778-2399
Practice Address - Country:US
Practice Address - Phone:727-584-9500
Practice Address - Fax:727-584-9502
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-19
Last Update Date:2008-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLK6470Medicare ID - Type UnspecifiedGROUP NUMBER