Provider Demographics
NPI:1538595301
Name:SOURCE SURGICAL INC
Entity type:Organization
Organization Name:SOURCE SURGICAL INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JOEL
Authorized Official - Middle Name:N/A
Authorized Official - Last Name:CREGUT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-234-3980
Mailing Address - Street 1:644 CESERY BLVD STE 315
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32211-7165
Mailing Address - Country:US
Mailing Address - Phone:904-234-3980
Mailing Address - Fax:904-374-5737
Practice Address - Street 1:644 CESERY BLVD STE 315
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32211-7165
Practice Address - Country:US
Practice Address - Phone:904-234-3980
Practice Address - Fax:904-374-5737
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-09-24
Last Update Date:2020-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies