MEDICARE: JOHN W ROYALTY DO PA

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

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	34171	OTHER	FL	BLUE CROSS BLUE SHIELD

General Provider Information

NPI Number	:	1558420083
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JOHN W ROYALTY DO PA

Provider Business Mailing Address
First Line	:	3402 N LECANTO HWY
Second Line	:	SUITE C
City	:	BEVERLY HILLS
State	:	FL
Zip	:	34465-3570
Country	:	US
Telephone Number	:	352-563-5488
Fax Number	:	352-563-6328

Provider Business Practice Location Address
First Line	:	3402 N LECANTO HWY
Second Line	:	SUITE C
City	:	BEVERLY HILLS
State	:	FL
Zip	:	34465-3570
Country	:	US
Telephone Number	:	352-563-5488
Fax Number	:	352-563-6328

Authorized Official
Title or Position	:	OWNER
Name	:	MR. JOHN WAYNE ROYALTY
Credential	:	DO
Telephone Number	:	352-563-5488

Provider Enumeration Date	:	12/08/2006
Last Update Date	:	02/06/2015

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Directions to “JOHN W ROYALTY DO PA ” Practice Location

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