Healthcare Provider Details

I. General information

NPI: 1992183545
Provider Name (Legal Business Name): SUNCOAST VASCULAR & GENERAL SURGERY PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/15/2015
Last Update Date: 05/15/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11535 W EMERALD OAKS DR
CRYSTAL RIVER FL
34428-2815
US

IV. Provider business mailing address

PO BOX 1085
CRYSTAL RIVER FL
34423-1085
US

V. Phone/Fax

Practice location:
  • Phone: 352-794-6191
  • Fax: 352-794-6193
Mailing address:
  • Phone: 352-794-6191
  • Fax: 352-794-6193

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License NumberOS8292
License Number StateFL

VIII. Authorized Official

Name: WILLIAM R GELINAS
Title or Position: OWNER
Credential: D.O.
Phone: 352-794-6191