MEDICARE: BRIDGES SURGICAL GROUP 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	208600000X	Surgery Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	94791	OTHER	FL	BCBS OF FL

General Provider Information

NPI Number	:	1598712796
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BRIDGES SURGICAL GROUP LLC

Provider Business Mailing Address
First Line	:	1900 NEBRASKA AVE
Second Line	:	SUITE 4
City	:	FORT PIERCE
State	:	FL
Zip	:	34950-4837
Country	:	US
Telephone Number	:	772-461-7500
Fax Number	:

Provider Business Practice Location Address
First Line	:	1900 NEBRASKA AVE
Second Line	:	SUITE 4
City	:	FORT PIERCE
State	:	FL
Zip	:	34950-4837
Country	:	US
Telephone Number	:	772-461-7500
Fax Number	:

Authorized Official
Title or Position	:	VP
Name	:	LOUIS JOSEPH
Credential	:
Telephone Number	:	772-461-7500

Provider Enumeration Date	:	05/31/2006
Last Update Date	:	04/20/2008

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