Provider Demographics
NPI:1003036237
Name:FLORIDA MEDICAL CLINIC, LLC
Entity Type:Organization
Organization Name:FLORIDA MEDICAL CLINIC, LLC
Other - Org Name:FLORIDA MEDICAL CLINIC PATHOLOGY LAB
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JOE
Authorized Official - Middle Name:I
Authorized Official - Last Name:DELATORRE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:813-780-8440
Mailing Address - Street 1:38135 MARKET SQ
Mailing Address - Street 2:
Mailing Address - City:ZEPHYRHILLS
Mailing Address - State:FL
Mailing Address - Zip Code:33542-7505
Mailing Address - Country:US
Mailing Address - Phone:813-780-1255
Mailing Address - Fax:813-780-9773
Practice Address - Street 1:17401 COMMERCE PARK BLVD STE 108
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33647-3507
Practice Address - Country:US
Practice Address - Phone:813-782-8311
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FLORIDA MEDICAL CLINIC, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-04-30
Last Update Date:2020-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical PathologyGroup - Multi-Specialty
No207ZP0105XAllopathic & Osteopathic PhysiciansPathologyClinical Pathology/Laboratory MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL690006221OtherRR MEDICARE
FL800020546OtherLICENSE
FL800020546OtherLICENSE