Provider Demographics
NPI:1912209800
Name:SPECIALISTS IN UROLOGY SURGERY CENTER LLC
Entity Type:Organization
Organization Name:SPECIALISTS IN UROLOGY SURGERY CENTER LLC
Other - Org Name:SPECIALISTS IN UROLOGY SURGERY CENTER FORT MYERS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF ADMINISTRATIVE OFFICER
Authorized Official - Prefix:MS
Authorized Official - First Name:JACQUELINE
Authorized Official - Middle Name:
Authorized Official - Last Name:LUCIA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:239-963-7365
Mailing Address - Street 1:4571 COLONIAL BLVD STE 200
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33966-1156
Mailing Address - Country:US
Mailing Address - Phone:239-963-7365
Mailing Address - Fax:239-322-5617
Practice Address - Street 1:4571 COLONIAL BLVD
Practice Address - Street 2:SUITE 200
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33966
Practice Address - Country:US
Practice Address - Phone:239-434-6300
Practice Address - Fax:239-325-2285
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-26
Last Update Date:2018-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1334261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical