=====================================================
General NPI Number Information
=====================================================
NPI Number | 1639105455
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ENDOSURG OUTPATIENT CENTER LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/23/2006
-----------------------------------------------------
Last Update Date | 01/09/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 13838 N US HIGHWAY 441
-----------------------------------------------------
City | LADY LAKE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32159-8904
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 352-753-1612
-----------------------------------------------------
Fax | 352-728-5497
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 13838 N US HIGHWAY 441
-----------------------------------------------------
City | LADY LAKE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32159-8904
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 352-753-1612
-----------------------------------------------------
Fax | 352-728-5497
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DOCTOR
-----------------------------------------------------
Name | LILY TRAN
-----------------------------------------------------
Credential | M.D
-----------------------------------------------------
Telephone | 352-323-8868
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QA1903X
-----------------------------------------------------
Taxonomy Name | Ambulatory Surgical Clinic/Center
-----------------------------------------------------
License Number | 1115
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------