Provider Demographics
NPI:1871812289
Name:SURGICAL GROUP OF WINTER PARK LLC
Entity type:Organization
Organization Name:SURGICAL GROUP OF WINTER PARK LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:ROBINSON
Authorized Official - Last Name:BENNETT
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:407-673-9992
Mailing Address - Street 1:232 OSCEOLA CT
Mailing Address - Street 2:
Mailing Address - City:WINTER PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32789-4431
Mailing Address - Country:US
Mailing Address - Phone:407-673-9992
Mailing Address - Fax:407-673-9902
Practice Address - Street 1:2828 CASA ALOMA WAY
Practice Address - Street 2:SUITE 100
Practice Address - City:WINTER PARK
Practice Address - State:FL
Practice Address - Zip Code:32792-2223
Practice Address - Country:US
Practice Address - Phone:407-673-9992
Practice Address - Fax:407-673-9902
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-05-25
Last Update Date:2013-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS0003899208600000X, 2086S0129X, 208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
No2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Single Specialty
No208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)Group - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLE32175Medicare UPIN