| Entity Name: | ST. GEORGE SPINAL CLINIC, PA |
| Jurisdiction: | FLORIDA |
| Filing Type: | Domestic Profit |
| Status: | Active |
| Date Filed: | 26 Apr 2004 (21 years ago) |
| Document Number: | P04000070563 |
| FEI/EIN Number | 201132386 |
| Address: | 4469 N STATE ROUTE 7, LAUDERDALE LAKES, FL, 33319 |
| Mail Address: | 4469 N SR 7, Lauderdale lakes, FL, 33319, US |
| ZIP code: | 33319 |
| County: | Broward |
| Place of Formation: | FLORIDA |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1609898683 | 2006-07-25 | 2011-08-26 | PO BOX 10693, RIVIERA BEACH, FL, 334190693, US | 4469 N STATE ROAD 7, LAUDERDALE LAKES, FL, 333195876, US | |||||||||||||||||||||||||||||||||||||
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| Phone | +1 954-486-1966 |
| Fax | 9544869115 |
Authorized person
| Name | DR. WAGDY B. TADROS |
| Role | PHYSICIAN |
| Phone | 9544861966 |
Taxonomy
| Taxonomy Code | 207R00000X - Internal Medicine Physician |
| License Number | ME65248 |
| State | FL |
| Is Primary | Yes |
Other Provider Identifiers
| Issuer | AETNA |
| Number | 2621902 |
| State | FL |
| Issuer | BCBS ID |
| Number | 25940 |
| State | FL |
| Issuer | AVMED |
| Number | 234955 |
| State | FL |
| Name | Role | Address |
|---|---|---|
| TADROS WAGDY B | Agent | 6559 NEW PORT LAKE CIRCLE, BOCA RATON, FL, 33496 |
| Name | Role | Address |
|---|---|---|
| TADROS WAGDY BMD | Manager | 4469 N SR 7, Lauderdale lakes, FL, 33319 |
| Name | Role | Address |
|---|---|---|
| TADROS WAGDY BMD | Director | 4469 N SR 7, Lauderdale lakes, FL, 33319 |
| Event Type | Filed Date | Value | Description |
|---|---|---|---|
| CHANGE OF MAILING ADDRESS | 2017-01-08 | 4469 N STATE ROUTE 7, LAUDERDALE LAKES, FL 33319 | No data |
| REGISTERED AGENT ADDRESS CHANGED | 2008-01-24 | 6559 NEW PORT LAKE CIRCLE, BOCA RATON, FL 33496 | No data |
| CHANGE OF PRINCIPAL ADDRESS | 2006-01-09 | 4469 N STATE ROUTE 7, LAUDERDALE LAKES, FL 33319 | No data |
| Name | Date |
|---|---|
| ANNUAL REPORT | 2025-01-29 |
| ANNUAL REPORT | 2024-02-13 |
| ANNUAL REPORT | 2023-02-03 |
| ANNUAL REPORT | 2022-01-26 |
| ANNUAL REPORT | 2021-02-04 |
| ANNUAL REPORT | 2020-01-22 |
| ANNUAL REPORT | 2019-03-12 |
| ANNUAL REPORT | 2018-03-26 |
| ANNUAL REPORT | 2017-01-08 |
| ANNUAL REPORT | 2016-01-27 |
Date of last update: 01 Feb 2025
Sources: Florida Department of State
