1811182199 NPI number — DR. MICHAEL BRADLEY SMALL M.D.

Table of content: DR. MICHAEL BRADLEY SMALL M.D. (NPI 1811182199)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1811182199 NPI number — DR. MICHAEL BRADLEY SMALL M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SMALL
Provider First Name:
MICHAEL
Provider Middle Name:
BRADLEY
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

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:
1811182199
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/22/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2995 DREW ST FL 2
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CLEARWATER
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33759-3012
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
727-532-1355
Provider Business Mailing Address Fax Number:
813-635-2613

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4211 VAN DYKE RD
Provider Second Line Business Practice Location Address:
#200
Provider Business Practice Location Address City Name:
LUTZ
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33558-8005
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
813-264-6490
Provider Business Practice Location Address Fax Number:
813-443-8143
Provider Enumeration Date:
09/11/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207RG0100X , with the licence number:  ME104627 , 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: 003017701 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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