MEDICARE: TRAUMA & SPECIALTY SURGERY INSTITUTE, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2086S0102X	Surgical Critical Care Physician	ME65570	FL
2	2086S0127X	Trauma Surgery Physician	ME65570	FL
3	2086S0129X	Vascular Surgery Physician	ME65570	FL
4	208600000X	Surgery Physician	ME 65570	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	ME 65570	OTHER	FL	MEDICAL LICENSE

General Provider Information

NPI Number	:	1275667057
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TRAUMA & SPECIALTY SURGERY INSTITUTE, LLC

Provider Business Mailing Address
First Line	:	1076 FERN TRL
Second Line	:
City	:	WAYNESVILLE
State	:	NC
Zip	:	28786-9706
Country	:	US
Telephone Number	:	772-233-6166
Fax Number	:

Provider Business Practice Location Address
First Line	:	311 N CLYDE MORRIS BLVD STE 440
Second Line	:
City	:	DAYTONA BEACH
State	:	FL
Zip	:	32114-2757
Country	:	US
Telephone Number	:	386-252-0688
Fax Number	:	386-675-6401

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	MRS. LORI JAZAREVIC
Credential	:
Telephone Number	:	772-233-6166

Provider Enumeration Date	:	03/15/2007
Last Update Date	:	05/21/2021

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