Provider Demographics
NPI:1306028428
Name:SUNCOAST MEDICAL CLINIC LLC
Entity Type:Organization
Organization Name:SUNCOAST MEDICAL CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:L
Authorized Official - Last Name:ETTEL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:727-824-8357
Mailing Address - Street 1:601 7TH ST S
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33701-4704
Mailing Address - Country:US
Mailing Address - Phone:727-824-8357
Mailing Address - Fax:727-824-3132
Practice Address - Street 1:601 7TH ST S
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33701-4704
Practice Address - Country:US
Practice Address - Phone:727-824-8357
Practice Address - Fax:727-824-3132
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-30
Last Update Date:2008-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL0525480001Medicare NSC