Healthcare Provider Details

I. General information

NPI: 1275667057
Provider Name (Legal Business Name): TRAUMA & SPECIALTY SURGERY INSTITUTE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/15/2007
Last Update Date: 05/21/2021
Certification Date: 05/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

311 N CLYDE MORRIS BLVD STE 440
DAYTONA BEACH FL
32114-2757
US

IV. Provider business mailing address

1076 FERN TRL
WAYNESVILLE NC
28786-9706
US

V. Phone/Fax

Practice location:
  • Phone: 386-252-0688
  • Fax: 386-675-6401
Mailing address:
  • Phone: 772-233-6166
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberME 65570
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code2086S0102X
TaxonomySurgical Critical Care Physician
License NumberME65570
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code2086S0127X
TaxonomyTrauma Surgery Physician
License NumberME65570
License Number StateFL
# 4
Primary TaxonomyN
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License NumberME65570
License Number StateFL

VIII. Authorized Official

Name: MRS. LORI JAZAREVIC
Title or Position: OFFICE MANAGER
Credential:
Phone: 772-233-6166