1730206756 NPI number — SUNCOAST MEDICAL CLINIC, LLC

Table of content: (NPI 1730206756)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1730206756 NPI number — SUNCOAST MEDICAL CLINIC, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SUNCOAST MEDICAL CLINIC, 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:
1730206756
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
601 7TH ST S
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ST PETERSBURG
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33701-4704
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
727-894-1818
Provider Business Mailing Address Fax Number:
727-824-8392

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
601 7TH ST S
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ST PETERSBURG
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33701-4704
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
727-894-1818
Provider Business Practice Location Address Fax Number:
727-824-8392
Provider Enumeration Date:
03/23/2007

Additional Information

Authorized Official

Authorized Official Last Name:
COHEN
Authorized Official First Name:
STEVEN
Authorized Official Middle Name:
Authorized Official Title or Position:
PHYSICIAN
Authorized Official Telephone Number:
727-894-1818

Provider Taxonomy Codes

  • Taxonomy code: 2085R0202X , with the licence number:  141168 , 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: 141168 . This is a "FDA - FACILITY ID NUMBER" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: JR0521400 . This is a "DEPT. OF HEALTH - MAMMO" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: JR3252000 . This is a "DEPARTMENT OF HEALTH" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




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