Healthcare Provider Details

I. General information

NPI: 1770566218
Provider Name (Legal Business Name): SOUTH BAY SURGICAL GROUP PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/29/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4020 STATE ROAD 674 SUITE 19
SUN CITY CENTER FL
33573-5285
US

IV. Provider business mailing address

4020 STATE ROAD 674 SUITE 19
SUN CITY CENTER FL
33573-5285
US

V. Phone/Fax

Practice location:
  • Phone: 813-890-8004
  • Fax: 813-290-9691
Mailing address:
  • Phone: 813-890-8004
  • Fax: 813-290-9691

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberME62723
License Number StateFL

VIII. Authorized Official

Name: DAVID T GOLDSBERRY
Title or Position: PHYSICIAN
Credential: M.D.
Phone: 813-890-8004