Provider Demographics
NPI:1154839330
Name:FLORIDA CRANIOFACIAL ASSOCIATES LLC
Entity Type:Organization
Organization Name:FLORIDA CRANIOFACIAL ASSOCIATES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:PETER
Authorized Official - Middle Name:
Authorized Official - Last Name:KEMP
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:813-870-6000
Mailing Address - Street 1:4200 N ARMENIA AVE STE 3
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33607-6451
Mailing Address - Country:US
Mailing Address - Phone:813-870-6000
Mailing Address - Fax:813-870-6015
Practice Address - Street 1:4200 N ARMENIA AVE STE 3
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33607-6451
Practice Address - Country:US
Practice Address - Phone:813-870-6000
Practice Address - Fax:813-870-6015
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-22
Last Update Date:2018-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial SurgeryGroup - Single Specialty
No1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty