MEDICARE: SURFSIDE FAMILY MEDICINE 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	261QP2300X	Primary Care Clinic/Center	ME94076	FL

General Provider Information

NPI Number	:	1801028246
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SURFSIDE FAMILY MEDICINE LLC

Provider Business Mailing Address
First Line	:	3000 N ATLANTIC AVE STE 108
Second Line	:
City	:	COCOA BEACH
State	:	FL
Zip	:	32931-5029
Country	:	US
Telephone Number	:	321-799-2554
Fax Number	:	321-799-4750

Provider Business Practice Location Address
First Line	:	3000 N ATLANTIC AVE STE 108
Second Line	:
City	:	COCOA BEACH
State	:	FL
Zip	:	32931-5029
Country	:	US
Telephone Number	:	321-799-2554
Fax Number	:	321-799-4750

Authorized Official
Title or Position	:	OWNER/PHYSICIAN
Name	:	DR. OLGA DORJIMA EMGUSHOV
Credential	:	MD
Telephone Number	:	321-799-2554

Provider Enumeration Date	:	08/19/2009
Last Update Date	:	08/19/2009

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