MEDICARE: DELAND SURGERY CENTER LTD

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	809	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	64T	OTHER	FL	BCBS

General Provider Information

NPI Number	:	1083618656
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DELAND SURGERY CENTER LTD

Provider Business Mailing Address
First Line	:	651 W PLYMOUTH AVE
Second Line	:
City	:	DELAND
State	:	FL
Zip	:	32720-3259
Country	:	US
Telephone Number	:	386-738-6811
Fax Number	:

Provider Business Practice Location Address
First Line	:	651 W PLYMOUTH AVE
Second Line	:
City	:	DELAND
State	:	FL
Zip	:	32720-3259
Country	:	US
Telephone Number	:	386-738-6811
Fax Number	:

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	MS. CAROL A CAVANAGH
Credential	:
Telephone Number	:	386-738-6811

Provider Enumeration Date	:	06/10/2005
Last Update Date	:	04/01/2008

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Directions to “DELAND SURGERY CENTER LTD ” Practice Location

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