Healthcare Provider Details

I. General information

NPI: 1114447521
Provider Name (Legal Business Name): MINIMALLY INVASIVE SURGICAL SPECIALISTS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/27/2017
Last Update Date: 09/09/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8142 BELLARUS WAY STE 101
TRINITY FL
34655-1799
US

IV. Provider business mailing address

8142 BELLARUS WAY STE 101
TRINITY FL
34655-1799
US

V. Phone/Fax

Practice location:
  • Phone: 727-274-1330
  • Fax: 855-274-0039
Mailing address:
  • Phone: 727-274-1330
  • Fax: 855-274-0039

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberOS13410
License Number StateFL

VIII. Authorized Official

Name: TIFFANI SHELTON
Title or Position: OWNER, PHYSICIAN
Credential: DO
Phone: 727-274-1330