Provider Demographics
NPI:1164010187
Name:MINIMALLY INVASIVE SURGICAL AFFILIATES, LLC
Entity Type:Organization
Organization Name:MINIMALLY INVASIVE SURGICAL AFFILIATES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TALAL
Authorized Official - Middle Name:
Authorized Official - Last Name:HAMDAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:813-280-0202
Mailing Address - Street 1:PO BOX 4706
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33677-4706
Mailing Address - Country:US
Mailing Address - Phone:813-280-0202
Mailing Address - Fax:813-280-0203
Practice Address - Street 1:2715 N MACDILL AVE
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33607-2205
Practice Address - Country:US
Practice Address - Phone:813-280-0202
Practice Address - Fax:813-280-0203
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-01-05
Last Update Date:2021-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PENDINGOtherPENDING