Provider Demographics
NPI:1295918761
Name:ST. JOHNS SURGERY CENTER GROUP
Entity type:Organization
Organization Name:ST. JOHNS SURGERY CENTER GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:ALBERT
Authorized Official - Last Name:QUIGLEY
Authorized Official - Suffix:III
Authorized Official - Credentials:MD
Authorized Official - Phone:239-466-2020
Mailing Address - Street 1:6091 SOUTH POINTE BLVD
Mailing Address - Street 2:
Mailing Address - City:FT. MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33919
Mailing Address - Country:US
Mailing Address - Phone:239-466-2020
Mailing Address - Fax:239-466-7150
Practice Address - Street 1:8901 CONFERENCE DR
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33919-4895
Practice Address - Country:US
Practice Address - Phone:239-481-8833
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ST. JOHNS SURGERY CENTER INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-12-07
Last Update Date:2007-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9503907261QS0132X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS0132XAmbulatory Health Care FacilitiesClinic/CenterOphthalmologic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL079194600Medicaid
FL40411Medicare PIN
FL430028870Medicare PIN