MEDICARE: WEST PALM BEACH SURGICAL ASSISTING 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	363AS0400X	Surgical Physician Assistant

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	19-195	OTHER	FL	ABSA CERT - SURGICAL ASSISTANT - CERTIFIED

General Provider Information

NPI Number	:	1710513056
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WEST PALM BEACH SURGICAL ASSISTING LLC

Provider Business Mailing Address
First Line	:	PO BOX 210241
Second Line	:
City	:	ROYAL PALM BEACH
State	:	FL
Zip	:	33421-0241
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	10628 PASO FINO DR
Second Line	:
City	:	LAKE WORTH
State	:	FL
Zip	:	33449-8018
Country	:	US
Telephone Number	:	561-631-8171
Fax Number	:	561-631-8171

Authorized Official
Title or Position	:	SA-C
Name	:	MR. JOHN SANTORO
Credential	:
Telephone Number	:	561-631-8171

Provider Enumeration Date	:	03/18/2020
Last Update Date	:	05/17/2020

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