MEDICARE: RAULERSON GENERAL SURGERY 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

General Provider Information

NPI Number	:	1699719427
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RAULERSON GENERAL SURGERY GROUP LLC

Provider Business Mailing Address
First Line	:	109 NE 19TH DR
Second Line	:
City	:	OKEECHOBEE
State	:	FL
Zip	:	34972-1933
Country	:	US
Telephone Number	:	863-824-0210
Fax Number	:

Provider Business Practice Location Address
First Line	:	109 NE 19TH DR
Second Line	:
City	:	OKEECHOBEE
State	:	FL
Zip	:	34972-1933
Country	:	US
Telephone Number	:	863-824-0210
Fax Number	:

Authorized Official
Title or Position	:	VP
Name	:	LOUIS JOSEPH
Credential	:
Telephone Number	:	863-824-0210

Provider Enumeration Date	:	06/15/2006
Last Update Date	:	08/29/2007

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