MEDICARE: MEMORIAL SURGICARE LTD

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	AHCA989	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

General Provider Information

NPI Number	:	1942263363
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MEMORIAL SURGICARE LTD

Provider Business Mailing Address
First Line	:	3901 UNIVERSITY BLVD S
Second Line	:	SUITE 111
City	:	JACKSONVILLE
State	:	FL
Zip	:	32216-4377
Country	:	US
Telephone Number	:	904-448-1948
Fax Number	:	904-448-8889

Provider Business Practice Location Address
First Line	:	3901 UNIVERSITY BLVD S
Second Line	:	SUITE 111
City	:	JACKSONVILLE
State	:	FL
Zip	:	32216-4377
Country	:	US
Telephone Number	:	904-448-1948
Fax Number	:	904-448-8889

Authorized Official
Title or Position	:	VICE PRESIDENT
Name	:	DON LIEDTKE
Credential	:
Telephone Number	:	615-344-5507

Provider Enumeration Date	:	04/07/2006
Last Update Date	:	07/08/2008

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Directions to “MEMORIAL SURGICARE LTD ” Practice Location

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