Provider Demographics
NPI:1114258043
Name:SOUTH TAMPA MEDICAL ASSOCIATES INC
Entity Type:Organization
Organization Name:SOUTH TAMPA MEDICAL ASSOCIATES INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:LEONARD
Authorized Official - Middle Name:
Authorized Official - Last Name:MENNEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:813-890-8004
Mailing Address - Street 1:3614 W KENNEDY BLVD
Mailing Address - Street 2:SUITE B
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33609-2852
Mailing Address - Country:US
Mailing Address - Phone:813-890-8004
Mailing Address - Fax:813-290-9691
Practice Address - Street 1:3614 W KENNEDY BLVD
Practice Address - Street 2:SUITE B
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33609-2852
Practice Address - Country:US
Practice Address - Phone:813-890-8004
Practice Address - Fax:813-290-9691
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-15
Last Update Date:2010-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS0003135207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty