Healthcare Provider Details

I. General information

NPI: 1992162291
Provider Name (Legal Business Name): SURGICAL PRACTICE RESOURCE GROUP OF FLORIDA INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/19/2016
Last Update Date: 08/03/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

539 ROLLING ACRES RD
LADY LAKE FL
32159
US

IV. Provider business mailing address

PO BOX 489
LADY LAKE FL
32158-0489
US

V. Phone/Fax

Practice location:
  • Phone: 352-775-6348
  • Fax:
Mailing address:
  • Phone: 352-775-6348
  • Fax: 352-775-6352

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QU0200X
TaxonomyUrgent Care Clinic/Center
License Number
License Number StateFL

VIII. Authorized Official

Name: MR. STEVE ROTH
Title or Position: COO
Credential:
Phone: 352-775-6348