Provider Demographics
NPI:1205600806
Name:FKP TAMPA AMBULATORY SURGERY CENTER, LLC
Entity type:Organization
Organization Name:FKP TAMPA AMBULATORY SURGERY CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:TIM
Authorized Official - Middle Name:
Authorized Official - Last Name:BOGARDUS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-638-3180
Mailing Address - Street 1:1 PARKWAY NORTH BLVD STE 200S
Mailing Address - Street 2:
Mailing Address - City:DEERFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60015-2534
Mailing Address - Country:US
Mailing Address - Phone:847-388-2064
Mailing Address - Fax:
Practice Address - Street 1:514 EICHENFELD DR
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33511-5955
Practice Address - Country:US
Practice Address - Phone:813-358-1568
Practice Address - Fax:813-200-1840
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-11-14
Last Update Date:2024-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical