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General NPI Number Information
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NPI Number | 1114410214
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Entity Type | Organization
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Legal Business Name | SURGICAL CONSULTING GROUP PA
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Dates
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Enumeration Date | 06/13/2018
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Last Update Date | 07/15/2021
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Provider Practice Location Address
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Address Line | 3050 CHAMPION RING RD
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City | FORT MYERS
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State | FL
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Zip | 33905-5599
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Country | US
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Telephone | 941-621-6577
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 511644
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City | PUNTA GORDA
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State | FL
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Zip | 33951-1644
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Country | US
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Telephone | 207-240-3362
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. DAVID T RIDEOUT
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Credential | MD
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Telephone | 207-240-3362
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208600000X
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Taxonomy Name | Surgery Physician
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License Number | ME129811
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License Number State | FL
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