Provider Demographics
NPI:1861697096
Name:AVENTURA SURGICAL GROUP
Entity type:Organization
Organization Name:AVENTURA SURGICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SHANNON
Authorized Official - Middle Name:MICHELLE
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-933-8622
Mailing Address - Street 1:21110 BISCAYNE BLVD STE 400
Mailing Address - Street 2:
Mailing Address - City:AVENTURA
Mailing Address - State:FL
Mailing Address - Zip Code:33180-1252
Mailing Address - Country:US
Mailing Address - Phone:305-933-8622
Mailing Address - Fax:305-682-8430
Practice Address - Street 1:21110 BISCAYNE BLVD STE 400
Practice Address - Street 2:
Practice Address - City:AVENTURA
Practice Address - State:FL
Practice Address - Zip Code:33180-1252
Practice Address - Country:US
Practice Address - Phone:305-933-8622
Practice Address - Fax:305-682-8430
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-18
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS0003845174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL4996600003OtherCIGNA
FL20965953OtherAETNA
FL82412OtherBLUECROSS BLUE SHIELD
FL211520OtherAVMED
FL004770OtherNEIGHBORHOOD
FL08983OtherWELLCARE
FLAMERIGROUPOtherAMERIGROUP
FL20965953OtherAETNA
FLAMERIGROUPOtherAMERIGROUP