Provider Demographics
NPI:1770730459
Name:ST LUCIE SURGICAL ASSOCIATES PA
Entity type:Organization
Organization Name:ST LUCIE SURGICAL ASSOCIATES PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:IAN
Authorized Official - Middle Name:ANTHONY
Authorized Official - Last Name:CONCILIO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:772-873-8501
Mailing Address - Street 1:PO BOX 7665
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34985-7665
Mailing Address - Country:US
Mailing Address - Phone:772-873-8501
Mailing Address - Fax:772-873-8516
Practice Address - Street 1:8483 S US HIGHWAY 1
Practice Address - Street 2:SUITE 19
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34952-3360
Practice Address - Country:US
Practice Address - Phone:772-873-8501
Practice Address - Fax:772-873-8516
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-25
Last Update Date:2008-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
No2086S0127XAllopathic & Osteopathic PhysiciansSurgeryTrauma SurgeryGroup - Single Specialty
No2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Single Specialty
No2086X0206XAllopathic & Osteopathic PhysiciansSurgerySurgical OncologyGroup - Single Specialty