Provider Demographics
NPI:1174823207
Name:PHYSICIANS REGIONAL MEDICAL CENTER - PINE RIDGE
Entity Type:Organization
Organization Name:PHYSICIANS REGIONAL MEDICAL CENTER - PINE RIDGE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ELLIS
Authorized Official - Middle Name:B
Authorized Official - Last Name:NORSOPH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:813-899-6220
Mailing Address - Street 1:PO BOX 26309
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33623-6309
Mailing Address - Country:US
Mailing Address - Phone:813-899-6226
Mailing Address - Fax:813-985-8006
Practice Address - Street 1:6101 PINE RIDGE RD
Practice Address - Street 2:
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34119-3900
Practice Address - Country:US
Practice Address - Phone:813-899-6226
Practice Address - Fax:813-985-8006
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-22
Last Update Date:2010-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL4463261QR0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL4463OtherFLORIDA LICENSE