MEDICARE: RINEHART LAKE MARY SURGICAL 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	261QA1903X	Ambulatory Surgical Clinic/Center	1225	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1225	OTHER	FL	ASC LICENSE

General Provider Information

NPI Number	:	1811995137
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RINEHART LAKE MARY SURGICAL CENTER

Provider Business Mailing Address
First Line	:	917 RINEHART RD
Second Line	:	SUITE 1001
City	:	LAKE MARY
State	:	FL
Zip	:	32746-4802
Country	:	US
Telephone Number	:	407-708-5383
Fax Number	:	407-708-5396

Provider Business Practice Location Address
First Line	:	917 RINEHART RD
Second Line	:	SUITE 1001
City	:	LAKE MARY
State	:	FL
Zip	:	32746-4802
Country	:	US
Telephone Number	:	407-708-5383
Fax Number	:	407-708-5396

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	MRS. CHERYL M. MODICA
Credential	:	RN,LHRM
Telephone Number	:	407-708-5383

Provider Enumeration Date	:	07/11/2005
Last Update Date	:	08/22/2020

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