MEDICARE: PHYSICIAN ASSISTANT SURGICAL SERVICES, INC.

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	PA3266	FL

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	DF7491	OTHER	FL	RAILROAD MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	X1624	OTHER		BCBS

General Provider Information

NPI Number	:	1629001011
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PHYSICIAN ASSISTANT SURGICAL SERVICES, INC.

Provider Business Mailing Address
First Line	:	3002 SE BUR ST
Second Line	:
City	:	PORT SAINT LUCIE
State	:	FL
Zip	:	34952-5855
Country	:	US
Telephone Number	:	772-337-4243
Fax Number	:

Provider Business Practice Location Address
First Line	:	3002 SE BUR ST
Second Line	:
City	:	PORT SAINT LUCIE
State	:	FL
Zip	:	34952-5855
Country	:	US
Telephone Number	:	772-337-4243
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	RICHARD JOSEPH PALMERI
Credential	:	PA-C
Telephone Number	:	772-337-4243

Provider Enumeration Date	:	07/08/2006
Last Update Date	:	11/19/2007

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