1356997662 NPI number — TRIPLE GEM HEALTHCARE, INC.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1356997662 NPI number — TRIPLE GEM HEALTHCARE, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TRIPLE GEM HEALTHCARE, INC.
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:
1356997662
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/13/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4222 22ND AVE S # 531631
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAINT PETERSBURG
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33711-9998
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
833-724-6688
Provider Business Mailing Address Fax Number:
833-724-6688

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2650 1ST AVE 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:
33712-1108
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
833-724-6688
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/13/2019

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
STALL
Authorized Official First Name:
ROBERT
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO / PHYSICIAN
Authorized Official Telephone Number:
833-724-6688

Provider Taxonomy Codes

  • Taxonomy code: 208100000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2081P2900X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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