Basic Information
| Provider Information | |||||||||
| NPI: | 1578732889 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LARGO PHYSICIAN GROUP, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2000 HEALTH PARK DR | ||||||||
| Address2: | |||||||||
| City: | BRENTWOOD | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370274525 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6153737600 | ||||||||
| FaxNumber: | 8663461426 | ||||||||
| Practice Location | |||||||||
| Address1: | 11373 CORTEZ BLVD STE 408 | ||||||||
| Address2: | |||||||||
| City: | BROOKSVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 346135406 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3525927310 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/21/2008 | ||||||||
| LastUpdateDate: | 10/21/2020 | ||||||||
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| AuthorizedOfficialLastName: | JOHNSON | ||||||||
| AuthorizedOfficialFirstName: | WILLIAM | ||||||||
| AuthorizedOfficialMiddleName: | TEDRICK | ||||||||
| AuthorizedOfficialTitleorPosition: | DIVISION VP/AO | ||||||||
| AuthorizedOfficialTelephone: | 6153723375 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 10/21/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 72062A | 01 | FL | BCBS FL-WALSINGHAM | OTHER | 000757301 | 01 | FL | MEDICAID-WALSINGHAM LOCATION | OTHER | 000757303 | 01 | FL | MEDICAID-BARDMOOR LOCATION | OTHER | 72062B | 01 | FL | BCBS FL--38TH AVE N. | OTHER | 000757300 | 01 | FL | MEDICAID --INDIAN ROCKS LOCATION | OTHER | 72062 | 01 | FL | BCBS FL--INDIAN ROCKS | OTHER | 76062C | 01 | FL | BCBS FL-- BARDMOOR | OTHER |