MEDICARE: BEACHES FACIAL AND NASAL SURGERY CENTER

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	207YX0905X	Otolaryngology/Facial Plastic Surgery Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1639360258
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BEACHES FACIAL AND NASAL SURGERY CENTER

Provider Business Mailing Address
First Line	:	1361 13TH AVE S STE 125
Second Line	:
City	:	JACKSONVILLE BEACH
State	:	FL
Zip	:	32250-3260
Country	:	US
Telephone Number	:	904-249-2580
Fax Number	:

Provider Business Practice Location Address
First Line	:	1361 13TH AVE S STE 125
Second Line	:
City	:	JACKSONVILLE BEACH
State	:	FL
Zip	:	32250-3260
Country	:	US
Telephone Number	:	904-249-2580
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	SCOTT J TRIMAS
Credential	:	MDFACS
Telephone Number	:	904-249-2580

Provider Enumeration Date	:	08/08/2007
Last Update Date	:	02/14/2011

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