MEDICARE: PHYSICIANS SURGERY 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	815	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
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1770588584
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PHYSICIANS SURGERY CENTER LLC

Provider Business Mailing Address
First Line	:	4960 SW 72ND AVE STE 405
Second Line	:
City	:	MIAMI
State	:	FL
Zip	:	33155-5506
Country	:	US
Telephone Number	:	469-458-9222
Fax Number	:	540-918-7202

Provider Business Practice Location Address
First Line	:	4035 EVANS AVE
Second Line	:
City	:	FT MYERS
State	:	FL
Zip	:	33901-9308
Country	:	US
Telephone Number	:	239-788-0604
Fax Number	:	239-230-0041

Authorized Official
Title or Position	:	RCM MANAGER, CREDENTIALING & ENROLL
Name	:	SHANEKA TINCH
Credential	:
Telephone Number	:	470-798-7293

Provider Enumeration Date	:	06/17/2005
Last Update Date	:	04/08/2026

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