=====================================================
General NPI Number Information
=====================================================
NPI Number | 1164267746
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GC SURGICAL LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/26/2024
-----------------------------------------------------
Last Update Date | 12/03/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12361 HAGEN RANCH RD # 5032068
-----------------------------------------------------
City | BOYNTON BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33437-4174
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-799-7500
-----------------------------------------------------
Fax | 561-516-6538
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 12361 HAGEN RANCH RD # 5032068
-----------------------------------------------------
City | BOYNTON BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33437-4174
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-799-7500
-----------------------------------------------------
Fax | 561-516-6538
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGER
-----------------------------------------------------
Name | MRS. GEORGETTE CAROLINI
-----------------------------------------------------
Credential | CSFA
-----------------------------------------------------
Telephone | 305-799-7500
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363AS0400X
-----------------------------------------------------
Taxonomy Name | Surgical Physician Assistant
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------