MEDICARE: SOUTHWEST FLORIDA FACIAL PLASTIC SURGERY ASSOCIATES 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	174400000X	Specialist	ME81906	FL

General Provider Information

NPI Number	:	1245481597
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTHWEST FLORIDA FACIAL PLASTIC SURGERY ASSOCIATES INC.

Provider Business Mailing Address
First Line	:	9407 CYPRESS LAKE DR STE A
Second Line	:
City	:	FORT MYERS
State	:	FL
Zip	:	33919-0910
Country	:	US
Telephone Number	:	239-473-7390
Fax Number	:

Provider Business Practice Location Address
First Line	:	9407 CYPRESS LAKE DR STE A
Second Line	:
City	:	FORT MYERS
State	:	FL
Zip	:	33919-0910
Country	:	US
Telephone Number	:	239-473-7390
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. STEPHEN A PRENDIVILLE
Credential	:	M.D.
Telephone Number	:	239-437-3900

Provider Enumeration Date	:	10/06/2008
Last Update Date	:	05/20/2014

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