1447218904 NPI number — MR. PAUL A. SPORN MD

Table of content: DR. KRISTEN L BANNISTER M.D. (NPI 1649278961)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1447218904 NPI number — MR. PAUL A. SPORN MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SPORN
Provider First Name:
PAUL
Provider Middle Name:
A.
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
SPORN
Provider Other First Name:
PAUL
Provider Other Middle Name:
A
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD PA
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1447218904
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/25/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2727 W DR MARTIN LUTHER KING BLVD
Provider Second Line Business Mailing Address:
STE 630
Provider Business Mailing Address City Name:
TAMPA
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33607-6378
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
813-876-6000
Provider Business Mailing Address Fax Number:
813-876-0590

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2727 W DR MARTIN LUTHER KING BLVD
Provider Second Line Business Practice Location Address:
STE 630
Provider Business Practice Location Address City Name:
TAMPA
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33607-6378
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
813-876-6000
Provider Business Practice Location Address Fax Number:
813-876-0590
Provider Enumeration Date:
05/03/2006

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: 207V00000X , with the licence number:  ME46290 , 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: 044500200 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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