Provider Demographics
NPI:1780835959
Name:SURGICAL CONSULTANTS OF SOUTHWEST FLORIDA, LLC
Entity type:Organization
Organization Name:SURGICAL CONSULTANTS OF SOUTHWEST FLORIDA, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:L
Authorized Official - Last Name:BASS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:239-494-8777
Mailing Address - Street 1:4519 TILTON CT
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33907-1214
Mailing Address - Country:US
Mailing Address - Phone:239-494-8777
Mailing Address - Fax:239-288-7139
Practice Address - Street 1:4519 TILTON CT
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33907-1214
Practice Address - Country:US
Practice Address - Phone:239-494-8777
Practice Address - Fax:239-288-7139
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-07
Last Update Date:2024-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME66691208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLEU499AOtherPTAN
FL003437100Medicaid