MEDICARE: ALLIED SURGICAL OF SOUTH FLORIDA

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	363AS0400X	Surgical Physician Assistant	PA9102746	FL

General Provider Information

NPI Number	:	1578041208
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ALLIED SURGICAL OF SOUTH FLORIDA

Provider Business Mailing Address
First Line	:	3255 NW 94TH AVE UNIT 8154
Second Line	:
City	:	CORAL SPRINGS
State	:	FL
Zip	:	33075-2009
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	7201 N UNIVERSITY DR
Second Line	:
City	:	TAMARAC
State	:	FL
Zip	:	33321-2913
Country	:	US
Telephone Number	:	954-854-0628
Fax Number	:

Authorized Official
Title or Position	:	OWNER/AMBR
Name	:	STORM ESTELLE
Credential	:
Telephone Number	:	954-854-0628

Provider Enumeration Date	:	08/03/2018
Last Update Date	:	04/02/2020

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