Basic Information
| Provider Information | |||||||||
| NPI: | 1528049962 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MORTON PLANT HEALTH SERVICES INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | BAYCARE OUTPATIENT IMAGING | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2995 DREW STREET | ||||||||
| Address2: | EAST BLDG 2ND FLOOR | ||||||||
| City: | CLEARWATER | ||||||||
| State: | FL | ||||||||
| PostalCode: | 33759 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7272819390 | ||||||||
| FaxNumber: | 8136352613 | ||||||||
| Practice Location | |||||||||
| Address1: | 8787 BRYAN DAIRY RD | ||||||||
| Address2: | |||||||||
| City: | LARGO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 337771251 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7273945900 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/11/2005 | ||||||||
| LastUpdateDate: | 01/18/2019 | ||||||||
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| AuthorizedOfficialLastName: | CUBERO | ||||||||
| AuthorizedOfficialFirstName: | TAMBLYN | ||||||||
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| AuthorizedOfficialTitleorPosition: | MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 7272819390 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 063659204 | 05 | FL | MEDICAID |