Provider Demographics
NPI:1235101833
Name:CMS ST PETERSBURG
Entity Type:Organization
Organization Name:CMS ST PETERSBURG
Other - Org Name:FLORIDA DEPARTMENT OF HEALTH CHILDRENS MEDICAL SERVICES
Other - Org Type:Other Name
Authorized Official - Title/Position:PROGRAM ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:PATRICIA
Authorized Official - Middle Name:B
Authorized Official - Last Name:KOPP
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:813-396-9798
Mailing Address - Street 1:3251 3RD AVE N
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURGH
Mailing Address - State:FL
Mailing Address - Zip Code:33713
Mailing Address - Country:US
Mailing Address - Phone:727-893-2775
Mailing Address - Fax:727-893-1101
Practice Address - Street 1:3251 3RD AVE N
Practice Address - Street 2:
Practice Address - City:ST PETERSBURGH
Practice Address - State:FL
Practice Address - Zip Code:33713
Practice Address - Country:US
Practice Address - Phone:727-893-2775
Practice Address - Fax:727-893-1101
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-07
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL251K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare