Provider Demographics
NPI:1770566218
Name:SOUTH BAY SURGICAL GROUP PA
Entity type:Organization
Organization Name:SOUTH BAY SURGICAL GROUP PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:T
Authorized Official - Last Name:GOLDSBERRY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:813-890-8004
Mailing Address - Street 1:4020 STATE ROAD 674
Mailing Address - Street 2:SUITE 19
Mailing Address - City:SUN CITY CENTER
Mailing Address - State:FL
Mailing Address - Zip Code:33573-5285
Mailing Address - Country:US
Mailing Address - Phone:813-890-8004
Mailing Address - Fax:813-290-9691
Practice Address - Street 1:4020 STATE ROAD 674
Practice Address - Street 2:SUITE 19
Practice Address - City:SUN CITY CENTER
Practice Address - State:FL
Practice Address - Zip Code:33573-5285
Practice Address - Country:US
Practice Address - Phone:813-890-8004
Practice Address - Fax:813-290-9691
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-29
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME62723174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLK0222Medicare ID - Type Unspecified