1649604364 NPI number — GREATER TAMPA BAY PHYSICIAN NETWORK, LLC

Table of content: (NPI 1649604364)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1649604364 NPI number — GREATER TAMPA BAY PHYSICIAN NETWORK, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GREATER TAMPA BAY PHYSICIAN NETWORK, LLC
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:
1649604364
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/15/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 742717
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ATLANTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30374-2717
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
615-373-7600
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1615 PASADENA AVE S STE 430
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SOUTH PASADENA
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33707-4521
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
727-397-0606
Provider Business Practice Location Address Fax Number:
727-397-6161
Provider Enumeration Date:
08/29/2013

Additional Information

Authorized Official

Authorized Official Last Name:
JOHNSON
Authorized Official First Name:
WILLIAM
Authorized Official Middle Name:
TEDERICK
Authorized Official Title or Position:
GROUP VICE PRESIDENT/AO
Authorized Official Telephone Number:
615-372-3375

Provider Taxonomy Codes

  • Taxonomy code: 207RC0000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207R00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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