MEDICARE: ENDOSURG OUTPATIENT CENTER 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	261QA1903X	Ambulatory Surgical Clinic/Center	1115	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1639105455
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ENDOSURG OUTPATIENT CENTER LLC

Provider Business Mailing Address
First Line	:	13838 N US HIGHWAY 441
Second Line	:
City	:	LADY LAKE
State	:	FL
Zip	:	32159-8904
Country	:	US
Telephone Number	:	352-753-1612
Fax Number	:	352-728-5497

Provider Business Practice Location Address
First Line	:	13838 N US HIGHWAY 441
Second Line	:
City	:	LADY LAKE
State	:	FL
Zip	:	32159-8904
Country	:	US
Telephone Number	:	352-753-1612
Fax Number	:	352-728-5497

Authorized Official
Title or Position	:	DOCTOR
Name	:	LILY TRAN
Credential	:	M.D
Telephone Number	:	352-323-8868

Provider Enumeration Date	:	06/23/2006
Last Update Date	:	01/09/2014

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Directions to “ENDOSURG OUTPATIENT CENTER LLC ” Practice Location

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