MEDICARE: MIAMI BEACH SURGERY CENTER, 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	261QA1903X	Ambulatory Surgical Clinic/Center

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1578188983	OTHER	FL	OUT OF NETWORK PROVIDER

General Provider Information

NPI Number	:	1578188983
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MIAMI BEACH SURGERY CENTER, LLC

Provider Business Mailing Address
First Line	:	400 W 41ST ST STE 512
Second Line	:
City	:	MIAMI BEACH
State	:	FL
Zip	:	33140-3517
Country	:	US
Telephone Number	:	305-405-6910
Fax Number	:	305-405-6912

Provider Business Practice Location Address
First Line	:	400 W 41ST ST STE 512
Second Line	:
City	:	MIAMI BEACH
State	:	FL
Zip	:	33140-3517
Country	:	US
Telephone Number	:	305-405-6910
Fax Number	:	305-405-6912

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. GABRIEL ELLIS SALLOUM
Credential	:
Telephone Number	:	305-742-7985

Provider Enumeration Date	:	06/11/2020
Last Update Date	:	09/04/2020

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