MEDICARE: COLOPROCTOLOGY SURGICARE, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QA1903X	Ambulatory Surgical Clinic/Center
2	261QE0800X	Endoscopy Clinic/Center

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1043203128	OTHER		PHYSICIAN NPI#

General Provider Information

NPI Number	:	1053563833
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COLOPROCTOLOGY SURGICARE, INC.

Provider Business Mailing Address
First Line	:	2110 SEABROOK CIR
Second Line	:
City	:	SEABROOK
State	:	TX
Zip	:	77586-1626
Country	:	US
Telephone Number	:	281-474-7171
Fax Number	:	281-474-7177

Provider Business Practice Location Address
First Line	:	2110 SEABROOK CIR
Second Line	:
City	:	SEABROOK
State	:	TX
Zip	:	77586-1626
Country	:	US
Telephone Number	:	281-474-7171
Fax Number	:	281-474-7177

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. MARCUS MICHAEL AQUINO
Credential	:	MD
Telephone Number	:	281-474-7171

Provider Enumeration Date	:	10/12/2008
Last Update Date	:	10/12/2008

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