Provider Demographics
NPI:1275642100
Name:THE REPRODUCTIVE MEDICINE GROUP
Entity Type:Organization
Organization Name:THE REPRODUCTIVE MEDICINE GROUP
Other - Org Name:THE REPRODUCTIVE MEDICINE GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF OPERATING OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:GUY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:813-914-7304
Mailing Address - Street 1:5245 E FLETCHER AVE
Mailing Address - Street 2:SUITE 1
Mailing Address - City:TEMPLE TERRACE
Mailing Address - State:FL
Mailing Address - Zip Code:33617-1126
Mailing Address - Country:US
Mailing Address - Phone:813-914-7304
Mailing Address - Fax:813-914-7314
Practice Address - Street 1:612 MEDICAL CARE DR
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33511-5937
Practice Address - Country:US
Practice Address - Phone:813-661-9114
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-30
Last Update Date:2022-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207VE0102X
FL60 909207VE0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207VE0102XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyReproductive EndocrinologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL10D0290313OtherCLIA NUMBER OF LAB
FLL800006333OtherFL STATE LICENSE OF LAB
FL21547OtherGROUP BCBS NUMBER
FL10D0290313OtherCLIA NUMBER OF LAB