Provider Demographics
NPI:1780872705
Name:SURFSIDE FAMILY PRACTICE LLC
Entity type:Organization
Organization Name:SURFSIDE FAMILY PRACTICE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:
Authorized Official - First Name:HARRY
Authorized Official - Middle Name:ALLEN
Authorized Official - Last Name:EARLE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:321-799-2554
Mailing Address - Street 1:3000 N ATLANTIC AVE
Mailing Address - Street 2:SUITE 108
Mailing Address - City:COCOA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32931-5078
Mailing Address - Country:US
Mailing Address - Phone:321-799-2554
Mailing Address - Fax:321-799-4750
Practice Address - Street 1:3000 N ATLANTIC AVE
Practice Address - Street 2:SUITE 108
Practice Address - City:COCOA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32931-5078
Practice Address - Country:US
Practice Address - Phone:321-799-2554
Practice Address - Fax:321-799-4750
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-04
Last Update Date:2008-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME00059920261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL055552599Medicaid
FLAG997OtherMEDICARE PTAN
FLF14844Medicare UPIN