Healthcare Provider Details

I. General information

NPI: 1770730459
Provider Name (Legal Business Name): ST LUCIE SURGICAL ASSOCIATES PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/25/2008
Last Update Date: 09/30/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8483 S US HIGHWAY 1 SUITE 19
PORT ST LUCIE FL
34952-3360
US

IV. Provider business mailing address

PO BOX 7665
PORT ST LUCIE FL
34985-7665
US

V. Phone/Fax

Practice location:
  • Phone: 772-873-8501
  • Fax: 772-873-8516
Mailing address:
  • Phone: 772-873-8501
  • Fax: 772-873-8516

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2086S0127X
TaxonomyTrauma Surgery Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code2086X0206X
TaxonomySurgical Oncology Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. IAN ANTHONY CONCILIO
Title or Position: OWNER/PHYSICIAN
Credential: M.D.
Phone: 772-873-8501