Provider Demographics
NPI:1225027493
Name:PROVIDENCE MEDICAL CORPORATION
Entity Type:Organization
Organization Name:PROVIDENCE MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:RICHARD
Authorized Official - Last Name:LEVERING
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:727-540-9377
Mailing Address - Street 1:PO BOX 48833
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33743-8833
Mailing Address - Country:US
Mailing Address - Phone:727-540-9377
Mailing Address - Fax:727-540-9387
Practice Address - Street 1:3350 ULMERTON RD
Practice Address - Street 2:SUITE 16
Practice Address - City:CLEARWATER
Practice Address - State:FL
Practice Address - Zip Code:33762-3397
Practice Address - Country:US
Practice Address - Phone:727-540-9377
Practice Address - Fax:727-540-9387
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-19
Last Update Date:2014-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL326332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL022415400Medicaid
FLR9114OtherBCBS OF FLORIDA
FLR9114OtherBCBS OF FLORIDA