Healthcare Provider Details

I. General information

NPI: 1871812289
Provider Name (Legal Business Name): SURGICAL GROUP OF WINTER PARK LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/25/2010
Last Update Date: 08/22/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2828 CASA ALOMA WAY SUITE 100
WINTER PARK FL
32792-2223
US

IV. Provider business mailing address

232 OSCEOLA CT
WINTER PARK FL
32789-4431
US

V. Phone/Fax

Practice location:
  • Phone: 407-673-9992
  • Fax: 407-673-9902
Mailing address:
  • Phone: 407-673-9992
  • Fax: 407-673-9902

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberOS0003899
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License NumberOS0003899
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License NumberOS0003899
License Number StateFL

VIII. Authorized Official

Name: DR. JOSEPH ROBINSON BENNETT
Title or Position: PRESIDENT
Credential: D.O
Phone: 407-673-9992