Provider Demographics
NPI:1770588584
Name:PHYSICIANS SURGERY CENTER LLC
Entity type:Organization
Organization Name:PHYSICIANS SURGERY CENTER LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICER AND AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:REBEKAH
Authorized Official - Middle Name:
Authorized Official - Last Name:HENSLEY-MARTIN
Authorized Official - Suffix:
Authorized Official - Credentials:CPCS, CPMSM
Authorized Official - Phone:757-846-6946
Mailing Address - Street 1:PO BOX 715803
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45271-5803
Mailing Address - Country:US
Mailing Address - Phone:239-788-0604
Mailing Address - Fax:239-230-0041
Practice Address - Street 1:4035 EVANS AVE
Practice Address - Street 2:
Practice Address - City:FT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33901-9308
Practice Address - Country:US
Practice Address - Phone:239-788-0604
Practice Address - Fax:239-230-0041
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-17
Last Update Date:2023-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL815261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL062967700Medicaid
FL062967700Medicaid