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General NPI Number Information
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NPI Number | 1770730459
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Entity Type | Organization
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Legal Business Name | ST LUCIE SURGICAL ASSOCIATES PA
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Dates
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Enumeration Date | 08/25/2008
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Last Update Date | 09/30/2008
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Provider Practice Location Address
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Address Line | 8483 S US HIGHWAY 1 SUITE 19
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City | PORT ST LUCIE
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State | FL
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Zip | 34952-3360
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Country | US
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Telephone | 772-873-8501
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Fax | 772-873-8516
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Provider Business Mailing Address
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Address Line | PO BOX 7665
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City | PORT ST LUCIE
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State | FL
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Zip | 34985-7665
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Country | US
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Telephone | 772-873-8501
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Fax | 772-873-8516
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Authorized Official
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Title or Position | OWNER/PHYSICIAN
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Name | DR. IAN ANTHONY CONCILIO
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Credential | M.D.
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Telephone | 772-873-8501
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2086S0127X
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Taxonomy Name | Trauma Surgery Physician
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 2086S0129X
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Taxonomy Name | Vascular Surgery Physician
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 2086X0206X
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Taxonomy Name | Surgical Oncology Physician
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License Number |
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License Number State |
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Taxonomy #4
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Taxonomy Code | 208600000X
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Taxonomy Name | Surgery Physician
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License Number |
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License Number State |
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