MEDICARE: PROFESSIONAL SURGICAL ASSISTANTS

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	261QM1300X	Multi-Specialty Clinic/Center
2	363AS0400X	Surgical Physician Assistant

General Provider Information

NPI Number	:	1871143453
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PROFESSIONAL SURGICAL ASSISTANTS

Provider Business Mailing Address
First Line	:	PO BOX 291613
Second Line	:
City	:	PORT ORANGE
State	:	FL
Zip	:	32129-1613
Country	:	US
Telephone Number	:	386-562-7052
Fax Number	:	800-821-4719

Provider Business Practice Location Address
First Line	:	120 ACKLINS CIR APT 112
Second Line	:
City	:	DAYTONA BEACH
State	:	FL
Zip	:	32119-9762
Country	:	US
Telephone Number	:	708-269-0669
Fax Number	:	800-821-4719

Authorized Official
Title or Position	:	OWNER
Name	:	MS. CHRISTINA H REPKA
Credential	:	RSA
Telephone Number	:	708-269-0669

Provider Enumeration Date	:	09/16/2019
Last Update Date	:	09/24/2019

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