Healthcare Provider Details

I. General information

NPI: 1669552519
Provider Name (Legal Business Name): SOUTHEASTERN SURGICAL GROUP PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/16/2006
Last Update Date: 07/17/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1401 CENTERVILLE ROAD SUITE 100
TALLAHASSEE FL
32308
US

IV. Provider business mailing address

1401 CENTERVILLE ROAD SUITE 100
TALLAHASSEE FL
32308
US

V. Phone/Fax

Practice location:
  • Phone: 850-877-5183
  • Fax: 850-656-1288
Mailing address:
  • Phone: 850-877-5183
  • Fax: 850-656-1288

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State

VIII. Authorized Official

Name: ROBERT D SNYDER
Title or Position: PRESIDENT
Credential: MD
Phone: 850-877-5183