Provider Demographics
NPI:1144415837
Name:PCA MEDICAL GROUP, INC.
Entity Type:Organization
Organization Name:PCA MEDICAL GROUP, INC.
Other - Org Name:STARUS MEDICAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT & CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:C.
Authorized Official - Middle Name:ROSS
Authorized Official - Last Name:BERRY
Authorized Official - Suffix:
Authorized Official - Credentials:MBA, CMPE, FAAMA
Authorized Official - Phone:813-440-4402
Mailing Address - Street 1:1715 N WEST SHORE BLVD
Mailing Address - Street 2:SUITE 780
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33607-3932
Mailing Address - Country:US
Mailing Address - Phone:813-440-4402
Mailing Address - Fax:813-440-4407
Practice Address - Street 1:34650 US 19 N
Practice Address - Street 2:SUITE 104
Practice Address - City:PALM HARBOR
Practice Address - State:FL
Practice Address - Zip Code:34684-2155
Practice Address - Country:US
Practice Address - Phone:727-789-2922
Practice Address - Fax:727-787-4288
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-06
Last Update Date:2016-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL006386604Medicaid
FL006386607Medicaid
FL006386602Medicaid
FL006386606Medicaid
FL006386601Medicaid
FL006386608Medicaid
FL006386605Medicaid
FL006386600Medicaid
FL006386603Medicaid
FL006386604Medicaid