Provider Demographics
NPI:1083085328
Name:TAMPA BAY SURGICAL GROUP LLP
Entity Type:Organization
Organization Name:TAMPA BAY SURGICAL GROUP LLP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:A
Authorized Official - Last Name:DIETRICK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:813-254-3016
Mailing Address - Street 1:606 S. BOULEVARD
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33606-2630
Mailing Address - Country:US
Mailing Address - Phone:813-254-3016
Mailing Address - Fax:813-254-3019
Practice Address - Street 1:606 S. BOULEVARD
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33606-2630
Practice Address - Country:US
Practice Address - Phone:813-254-3016
Practice Address - Fax:813-254-3019
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:TAMPA BAY SURGICAL GROUP LLP
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-10-13
Last Update Date:2015-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL000210000Medicaid
FL000210000Medicaid