Provider Demographics
NPI:1114457272
Name:NODAL MEDICAL CENTER LLC
Entity Type:Organization
Organization Name:NODAL MEDICAL CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DOCTOR
Authorized Official - Prefix:
Authorized Official - First Name:OSVANNY
Authorized Official - Middle Name:
Authorized Official - Last Name:NODAL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:813-488-4801
Mailing Address - Street 1:2123 W DR MARTIN LUTHER KING JR BLVD STE 101
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33607-6545
Mailing Address - Country:US
Mailing Address - Phone:813-488-4801
Mailing Address - Fax:813-405-4506
Practice Address - Street 1:2123 W DR MARTIN LUTHER KING JR BLVD STE 101
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33607-6545
Practice Address - Country:US
Practice Address - Phone:813-488-4801
Practice Address - Fax:813-405-4506
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-06-12
Last Update Date:2019-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLACN693208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty