Healthcare Provider Details

I. General information

NPI: 1205937117
Provider Name (Legal Business Name): PREMIUM SURGICAL SERVICES, L.L.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/25/2006
Last Update Date: 03/03/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11760 SW 40TH ST SUITE 729
MIAMI FL
33175-3582
US

IV. Provider business mailing address

11760 SW 40TH ST SUITE 729
MIAMI FL
33175-3582
US

V. Phone/Fax

Practice location:
  • Phone: 305-559-2779
  • Fax: 305-559-6119
Mailing address:
  • Phone: 305-559-2779
  • Fax: 305-559-6119

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VX0000X
TaxonomyObstetrics Physician
License Number
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code246ZS0410X
TaxonomySurgical Technologist
License Number
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number
License Number StateFL

VIII. Authorized Official

Name: MRS. MERCEDES AGUIRRE-TUDELA
Title or Position: PRESIDENT
Credential:
Phone: 305-559-2779