Provider Demographics
NPI:1275802621
Name:PREMIUM HEALTH SERVICES
Entity Type:Organization
Organization Name:PREMIUM HEALTH SERVICES
Other - Org Name:EXPRESS CARE OF TAMPA BAY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:KHAWAJA
Authorized Official - Middle Name:A
Authorized Official - Last Name:RAHMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:813-690-7589
Mailing Address - Street 1:107 W ROBERTSON ST
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:FL
Mailing Address - Zip Code:33511-5111
Mailing Address - Country:US
Mailing Address - Phone:813-651-4100
Mailing Address - Fax:813-651-4111
Practice Address - Street 1:6015 REX HALL LN
Practice Address - Street 2:
Practice Address - City:APOLLO BEACH
Practice Address - State:FL
Practice Address - Zip Code:33572-2657
Practice Address - Country:US
Practice Address - Phone:813-690-7589
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-14
Last Update Date:2011-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME79013261QU0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care