Provider Demographics
NPI:1225338510
Name:FANOURIOS I. FERDERIGOS, M.D., P.A.
Entity Type:Organization
Organization Name:FANOURIOS I. FERDERIGOS, M.D., P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:FANOURIOS
Authorized Official - Middle Name:I
Authorized Official - Last Name:FERDERIGOS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:727-789-3300
Mailing Address - Street 1:2626 TAMPA RD
Mailing Address - Street 2:SUITE 103
Mailing Address - City:PALM HARBOR
Mailing Address - State:FL
Mailing Address - Zip Code:34684-3155
Mailing Address - Country:US
Mailing Address - Phone:727-789-3300
Mailing Address - Fax:727-787-3454
Practice Address - Street 1:2626 TAMPA RD
Practice Address - Street 2:SUITE 103
Practice Address - City:PALM HARBOR
Practice Address - State:FL
Practice Address - Zip Code:34684-3155
Practice Address - Country:US
Practice Address - Phone:727-789-3300
Practice Address - Fax:727-787-3454
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-02
Last Update Date:2015-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0040703207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL220139000OtherFEDERAL WORKERS COMP PROV
FLGC512AOtherMEDICARE PTAN
FL0432120002Medicare NSC
FLGC512AOtherMEDICARE PTAN