Provider Demographics
NPI:1770601866
Name:MEDICAL SPECIALTY PROCEDURES, LC
Entity type:Organization
Organization Name:MEDICAL SPECIALTY PROCEDURES, LC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JOHNNY
Authorized Official - Middle Name:C
Authorized Official - Last Name:BENJAMIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:772-794-4236
Mailing Address - Street 1:1355 37TH ST
Mailing Address - Street 2:SUITE 304
Mailing Address - City:VERO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32960-7321
Mailing Address - Country:US
Mailing Address - Phone:772-794-4236
Mailing Address - Fax:
Practice Address - Street 1:1355 37TH ST
Practice Address - Street 2:SUITE 304
Practice Address - City:VERO BEACH
Practice Address - State:FL
Practice Address - Zip Code:32960-7321
Practice Address - Country:US
Practice Address - Phone:772-794-4236
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-27
Last Update Date:2008-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1137261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL10-C0001365Medicare ID - Type UnspecifiedASC IDENTIFICATION NUMBER