1083877047 NPI number — TAMPA BAY PEDIATRICS LLC

Table of content: (NPI 1083877047)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083877047 NPI number — TAMPA BAY PEDIATRICS LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TAMPA BAY PEDIATRICS LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1083877047
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 152682
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TAMPA
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33684-2682
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
813-743-7879
Provider Business Mailing Address Fax Number:
813-926-5358

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2302 W DR MARTIN LUTHER KING JR BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TAMPA
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33607-6406
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
813-743-7879
Provider Business Practice Location Address Fax Number:
813-926-5358
Provider Enumeration Date:
07/09/2008

Additional Information

Authorized Official

Authorized Official Last Name:
CARTAYA
Authorized Official First Name:
CARLOS
Authorized Official Middle Name:
M
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
813-743-7879

Provider Taxonomy Codes

  • Taxonomy code: 208000000X , with the licence number:  ME84690 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 284838 . This is a "AVMED" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 7189416 . This is a "AETNA" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 03286 . This is a "BCBS" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 4137152 . This is a "CIGNA" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 008401800 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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