1497494843 NPI number — TAMPA GENERAL PROVIDER NETWORK INC

Table of content: (NPI 1497494843)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1497494843 NPI number — TAMPA GENERAL PROVIDER NETWORK INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TAMPA GENERAL PROVIDER NETWORK 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:
1497494843
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/11/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 95000-7370
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PHILADELPHIA
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
19195-0001
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
855-235-3496
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4620 PGA BLVD STE 101
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PALM BEACH GARDENS
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33418-3991
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
561-832-1234
Provider Business Practice Location Address Fax Number:
561-832-5316
Provider Enumeration Date:
06/02/2022

Additional Information

Authorized Official

Authorized Official Last Name:
SCHWARZBERG
Authorized Official First Name:
ABRAHAM
Authorized Official Middle Name:
B
Authorized Official Title or Position:
VP
Authorized Official Telephone Number:
561-253-3980

Provider Taxonomy Codes

  • Taxonomy code: 208G00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 111415610 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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