1063436160 NPI number — LATAMIA M WHITE-GREEN MD

Table of content: LATAMIA M WHITE-GREEN MD (NPI 1063436160)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063436160 NPI number — LATAMIA M WHITE-GREEN MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WHITE-GREEN
Provider First Name:
LATAMIA
Provider Middle Name:
M
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
WHITE
Provider Other First Name:
LATAMIA
Provider Other Middle Name:
M
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1063436160
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/27/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 82969
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:
33682-2969
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
813-866-0930
Provider Business Mailing Address Fax Number:
813-405-3722

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12410 N NEBRASKA AVE
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:
33612-5352
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
813-397-5300
Provider Business Practice Location Address Fax Number:
813-865-0158
Provider Enumeration Date:
07/26/2006

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: 2084P0804X , with the licence number:  ME-93569 , 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: 051523807 . This is a "BLUE CROSS" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: 051530813 . This is a "BC FEDERAL EHBP" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: 51528383 . This is a "BCBS" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: 000007535 . This is a "BLUE CROSS" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: 051523805 . This is a "BLUE CROSS" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: 1549813 . This is a "UBH-BASIC" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: 003907200 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 051523806 . This is a "BLUE CROSS" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: 1549814 . This is a "UBH-PLUS" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".




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