Basic Information
| Provider Information | |||||||||
| NPI: | 1275642100 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | THE REPRODUCTIVE MEDICINE GROUP | ||||||||
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| OtherOrganizationName: | THE REPRODUCTIVE MEDICINE GROUP | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5245 E FLETCHER AVE | ||||||||
| Address2: | SUITE 1 | ||||||||
| City: | TEMPLE TERRACE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336171126 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8139147304 | ||||||||
| FaxNumber: | 8139147314 | ||||||||
| Practice Location | |||||||||
| Address1: | 612 MEDICAL CARE DR | ||||||||
| Address2: | |||||||||
| City: | BRANDON | ||||||||
| State: | FL | ||||||||
| PostalCode: | 335115937 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8136619114 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/30/2006 | ||||||||
| LastUpdateDate: | 05/31/2022 | ||||||||
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| AuthorizedOfficialLastName: | GUY | ||||||||
| AuthorizedOfficialFirstName: | SUSAN | ||||||||
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| AuthorizedOfficialTitleorPosition: | CHIEF OPERATING OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 8139147304 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 05/31/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207VE0102X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Reproductive Endocrinology | 207VE0102X | 60 909 | FL | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Reproductive Endocrinology |
ID Information
| ID | Type | State | Issuer | Description | 10D0290313 | 01 | FL | CLIA NUMBER OF LAB | OTHER | L800006333 | 01 | FL | FL STATE LICENSE OF LAB | OTHER | 21547 | 01 | FL | GROUP BCBS NUMBER | OTHER |