| Entity Name: | AMBULATORY SURGERY CENTER SUPPORT SERVICES, INC. |
| Jurisdiction: | FLORIDA |
| Filing Type: | Domestic Profit |
| Status: | Active |
| Date Filed: | 14 Aug 1991 (33 years ago) |
| Document Number: | S74045 |
| FEI/EIN Number | 593087811 |
| Address: | 502 E. NEW HAVEN AVENUE, MELBOURNE, FL, 32901, US |
| Mail Address: | 502 E. NEW HAVEN AVENUE, MELBOURNE, FL, 32901, US |
| ZIP code: | 32901 |
| County: | Brevard |
| Place of Formation: | FLORIDA |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1902857642 | 2006-05-15 | 2008-05-22 | 502 E NEW HAVEN AVE, MELBOURNE, FL, 329015427, US | 719 E NEW HAVEN AVE, MELBOURNE, FL, 329015459, US | |||||||||||||||||||||||||||
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| Phone | +1 321-727-2020 |
| Fax | 3219849547 |
| Phone | +1 321-984-4405 |
Authorized person
| Name | DR. WILLIAM J BROUSSARD |
| Role | PRESIDENT |
| Phone | 3217272020 |
Taxonomy
| Taxonomy Code | 207L00000X - Anesthesiology Physician |
| License Number | 19959 |
| State | FL |
| Is Primary | Yes |
Other Provider Identifiers
| Issuer | MEDICAID |
| Number | 259253300 |
| State | FL |
| Name | Role | Address |
|---|---|---|
| BARKER PATRICIA C | Agent | 502 E. NEW HAVEN AVENUE, MELBOURNE, FL, 32901 |
| Name | Role | Address |
|---|---|---|
| FREEMAN L. NMD | Director | 502 E. NEW HAVEN AVENUE, MELBOURNE, FL, 32901 |
| PAYLOR RALPH RMD | Director | 502 E. NEW HAVEN AVENUE, MELBOURNE, FL, 32901 |
| WEISER DAVID SMD | Director | 502 E. NEW HAVEN AVENUE, MELBOURNE, FL, 32901 |
| Name | Role | Address |
|---|---|---|
| FREEMAN L. NMD | Treasurer | 502 E. NEW HAVEN AVENUE, MELBOURNE, FL, 32901 |
| Name | Role | Address |
|---|---|---|
| PAYLOR RALPH RMD | President | 502 E. NEW HAVEN AVENUE, MELBOURNE, FL, 32901 |
| Name | Role | Address |
|---|---|---|
| WEISER DAVID SMD | Secretary | 502 E. NEW HAVEN AVENUE, MELBOURNE, FL, 32901 |
Date of last update: 02 Jan 2025
Sources: Florida Department of State
