MEDICARE: SUNCOAST RETINA INSTITUTE, P.L.

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	207W00000X	Ophthalmology Physician

General Provider Information

NPI Number	:	1902172331
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SUNCOAST RETINA INSTITUTE, P.L.

Provider Business Mailing Address
First Line	:	4916 26TH ST W
Second Line	:	STE 200
City	:	BRADENTON
State	:	FL
Zip	:	34207-1712
Country	:	US
Telephone Number	:	941-567-4078
Fax Number	:	941-869-7878

Provider Business Practice Location Address
First Line	:	4916 26TH ST W
Second Line	:	STE 200
City	:	BRADENTON
State	:	FL
Zip	:	34207-1712
Country	:	US
Telephone Number	:	941-567-4078
Fax Number	:	941-869-7878

Authorized Official
Title or Position	:	PRESIDENT/PHYSICIAN
Name	:	DR. PETER G LIVINGSTON
Credential	:	M.D.
Telephone Number	:	941-567-4078

Provider Enumeration Date	:	03/29/2012
Last Update Date	:	03/29/2012

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