MEDICARE: PALM COAST 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	PENDING	FL

General Provider Information

NPI Number	:	1831369610
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PALM COAST SURGERY CENTER LLC

Provider Business Mailing Address
First Line	:	28 OLD KINGS RD N
Second Line	:
City	:	PALM COAST
State	:	FL
Zip	:	32137-8226
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	21 HOSPITAL DRIVE
Second Line	:	SUITE 220
City	:	PALM COAST
State	:	FL
Zip	:	32164-2380
Country	:	US
Telephone Number	:	386-447-4408
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	JOHN M. RUSSELL
Credential	:	M.D.
Telephone Number	:	386-447-4440

Provider Enumeration Date	:	03/07/2008
Last Update Date	:	06/09/2008

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