Provider Demographics
NPI:1831195379
Name:LARGO SURGERY LLC
Entity type:Organization
Organization Name:LARGO SURGERY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICER AND AUTHORIZED
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:BOYD
Authorized Official - Last Name:BALDOCK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-234-5954
Mailing Address - Street 1:1401 W BAY DR
Mailing Address - Street 2:
Mailing Address - City:LARGO
Mailing Address - State:FL
Mailing Address - Zip Code:33770-2207
Mailing Address - Country:US
Mailing Address - Phone:727-585-9500
Mailing Address - Fax:727-584-1938
Practice Address - Street 1:1401 W BAY DR
Practice Address - Street 2:
Practice Address - City:LARGO
Practice Address - State:FL
Practice Address - Zip Code:33770-2207
Practice Address - Country:US
Practice Address - Phone:727-585-9500
Practice Address - Fax:727-584-1938
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-21
Last Update Date:2023-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL800005342291U00000X
FL781261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
No291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL070644200Medicaid
0771519008OtherCIGNA
FL691OtherBLUE CROSS/BLUE SHIELD