MEDICARE: GULF COAST SURGICAL ASSISTING PA

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	246ZS0410X	Surgical Technologist		FL

General Provider Information

NPI Number	:	1871772194
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GULF COAST SURGICAL ASSISTING PA

Provider Business Mailing Address
First Line	:	516 CRYSTAL DR
Second Line	:
City	:	MADEIRA BEACH
State	:	FL
Zip	:	33708-2373
Country	:	US
Telephone Number	:	727-548-9757
Fax Number	:	888-329-6432

Provider Business Practice Location Address
First Line	:	516 CRYSTAL DR
Second Line	:
City	:	MADEIRA BEACH
State	:	FL
Zip	:	33708-2373
Country	:	US
Telephone Number	:	727-548-9757
Fax Number	:	888-329-6432

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MICHELLE KENNEDY
Credential	:	CST
Telephone Number	:	727-442-6086

Provider Enumeration Date	:	11/02/2007
Last Update Date	:	10/10/2016

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