Healthcare Provider Details

I. General information

NPI: 1437630530
Provider Name (Legal Business Name): ORANGE BLOSSOM SURGICAL ASSOCIATES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/27/2018
Last Update Date: 08/27/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2043 LITTLE RD
TRINITY FL
34655-4421
US

IV. Provider business mailing address

2043 LITTLE RD
TRINITY FL
34655-4421
US

V. Phone/Fax

Practice location:
  • Phone: 727-999-3322
  • Fax: 727-440-8211
Mailing address:
  • Phone: 727-999-3322
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number
License Number State

VIII. Authorized Official

Name: REUT BARDACH
Title or Position: OWNER
Credential: MD
Phone: 727-846-7000