MEDICARE: THORACIC SURGERY OF INDIAN RIVER 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	208G00000X	Thoracic Surgery (Cardiothoracic Vascular Surgery) Physician	ME80733	FL

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
5	DN6310	OTHER	FL	MEDICARE RAILROAD

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2610659	OTHER	FL	CIGNA
2	35676	OTHER	FL	BCBS FLORIDA
3	613325100	OTHER		FEDERAL BLACK LUNG
4	7435144	OTHER	FL	AETNA
6	162138	OTHER	FL	WELLCARE
7	PRO6612	OTHER	FL	QUALITY HEALTH PLAN
8	1865828	OTHER	FL	AETNA FL

General Provider Information

NPI Number	:	1467628156
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	THORACIC SURGERY OF INDIAN RIVER LLC

Provider Business Mailing Address
First Line	:	14430 US HIGHWAY 1
Second Line	:	SUITE 102
City	:	SEBASTIAN
State	:	FL
Zip	:	32958-3289
Country	:	US
Telephone Number	:	772-589-2009
Fax Number	:	772-589-2299

Provider Business Practice Location Address
First Line	:	14430 US HIGHWAY 1
Second Line	:	SUITE 102
City	:	SEBASTIAN
State	:	FL
Zip	:	32958-3289
Country	:	US
Telephone Number	:	772-589-2009
Fax Number	:	772-589-2299

Authorized Official
Title or Position	:	MANAGING MEMBER
Name	:	DR. PETER A SEIRAFI
Credential	:	M.D.
Telephone Number	:	772-589-2009

Provider Enumeration Date	:	05/02/2008
Last Update Date	:	05/21/2009

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