Provider Demographics
NPI:1548254402
Name:LIVE OAK ENDOSCOPY CENTER, LLC
Entity type:Organization
Organization Name:LIVE OAK ENDOSCOPY CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:C.E.O.
Authorized Official - Prefix:MR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:J
Authorized Official - Last Name:MCCORMACK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:772-299-5005
Mailing Address - Street 1:275 18TH ST
Mailing Address - Street 2:SUITE 101
Mailing Address - City:VERO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32960-5555
Mailing Address - Country:US
Mailing Address - Phone:772-299-5005
Mailing Address - Fax:772-299-1340
Practice Address - Street 1:275 18TH ST
Practice Address - Street 2:SUITE 101
Practice Address - City:VERO BEACH
Practice Address - State:FL
Practice Address - Zip Code:32960-5555
Practice Address - Country:US
Practice Address - Phone:772-299-5005
Practice Address - Fax:772-299-1340
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-07
Last Update Date:2009-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1154261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL075390400Medicaid
FL6B6OtherBC BS FLORIDA
FL490005670OtherRAILROAD MEDICARE
4677223OtherCIGNA
A2882678OtherOXFORD HEALTH PLAN
4677223OtherCIGNA
FL075390400Medicaid
FL6B6OtherBC BS FLORIDA