=====================================================
General NPI Number Information
=====================================================
NPI Number | 1194788182
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SURGICAL PARK CENTER LTD
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/10/2006
-----------------------------------------------------
Last Update Date | 02/13/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9065 DADELAND BLVD
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33156
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-271-9100
-----------------------------------------------------
Fax | 866-678-6878
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9065 DADELAND BLVD
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33156
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-271-9100
-----------------------------------------------------
Fax | 866-678-6878
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | VP
-----------------------------------------------------
Name | WILLIAM GREGORY SWINNEY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 972-789-2877
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QA1903X
-----------------------------------------------------
Taxonomy Name | Ambulatory Surgical Clinic/Center
-----------------------------------------------------
License Number | 818
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------