Provider Demographics
NPI:1235398058
Name:ST ANTHONY'S PRIMARY CARE LLC
Entity Type:Organization
Organization Name:ST ANTHONY'S PRIMARY CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:TERESA
Authorized Official - Middle Name:
Authorized Official - Last Name:BRADLEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:727-532-1355
Mailing Address - Street 1:PO BOX 1830
Mailing Address - Street 2:
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33757-1830
Mailing Address - Country:US
Mailing Address - Phone:727-532-0002
Mailing Address - Fax:727-532-1318
Practice Address - Street 1:116 1ST ST N
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33701-3305
Practice Address - Country:US
Practice Address - Phone:727-895-5210
Practice Address - Fax:727-821-4297
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ST ANTHONY'S PRIMARY CARE LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-06-06
Last Update Date:2008-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME89948207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL5819820001Medicare NSC