Basic Information
| Provider Information | |||||||||
| NPI: | 1528492287 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GREATER TAMPA BAY PHYSICIAN SPECIALISTS, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2000 HEALTH PARK DR | ||||||||
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| City: | BRENTWOOD | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370274525 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6153737600 | ||||||||
| FaxNumber: | 8663461426 | ||||||||
| Practice Location | |||||||||
| Address1: | 602 S AUDUBON AVE | ||||||||
| Address2: | SUITE A | ||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336094217 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8138771415 | ||||||||
| FaxNumber: | 8178777602 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/29/2013 | ||||||||
| LastUpdateDate: | 10/15/2020 | ||||||||
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| AuthorizedOfficialLastName: | JOHNSON | ||||||||
| AuthorizedOfficialFirstName: | WILLIAM | ||||||||
| AuthorizedOfficialMiddleName: | TEDERICK | ||||||||
| AuthorizedOfficialTitleorPosition: | GROUP VICE PRESIDENT/AO | ||||||||
| AuthorizedOfficialTelephone: | 6153725372 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 10/15/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2086S0129X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | Vascular Surgery | 208600000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery |
No ID Information.