MEDICARE: WELLS SURGICAL SERVICES, LLC

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	208600000X	Surgery Physician	ME104932	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1174863872
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WELLS SURGICAL SERVICES, LLC

Provider Business Mailing Address
First Line	:	1201 MONUMENT RD
Second Line	:	SUITE 201B
City	:	JACKSONVILLE
State	:	FL
Zip	:	32225-7411
Country	:	US
Telephone Number	:	904-281-5878
Fax Number	:	904-724-9234

Provider Business Practice Location Address
First Line	:	1201 MONUMENT RD
Second Line	:	SUITE 201B
City	:	JACKSONVILLE
State	:	FL
Zip	:	32225-7411
Country	:	US
Telephone Number	:	904-281-5878
Fax Number	:	904-724-9234

Authorized Official
Title or Position	:	PRESIDENT
Name	:	CAROL PATRICIA BOWEN-WELLS
Credential	:	M.D.
Telephone Number	:	904-281-5878

Provider Enumeration Date	:	02/18/2013
Last Update Date	:	02/18/2013

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