=====================================================
General NPI Number Information
=====================================================
NPI Number | 1366499923
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TAMPA BAY CENTER FOR SPECIALIZED SURGERY INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/28/2006
-----------------------------------------------------
Last Update Date | 04/10/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2808 W DR MARTIN LUTHER KING JR BLVD
-----------------------------------------------------
City | TAMPA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33607-6306
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 813-874-2040
-----------------------------------------------------
Fax | 813-876-3438
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 152199
-----------------------------------------------------
City | TAMPA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33684-2199
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 813-874-2040
-----------------------------------------------------
Fax | 813-876-3438
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | FACILITY ADMINISTATOR
-----------------------------------------------------
Name | MS. MARY ELIZABETH DYKEMA
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 813-874-2040
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QA1903X
-----------------------------------------------------
Taxonomy Name | Ambulatory Surgical Clinic/Center
-----------------------------------------------------
License Number | 912
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------