Provider Demographics
NPI:1326037243
Name:PRICE, BRENT C (MD)
Entity Type:Individual
Prefix:DR
First Name:BRENT
Middle Name:C
Last Name:PRICE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 W MAIN ST
Mailing Address - Street 2:SUITE 108
Mailing Address - City:BABYLON
Mailing Address - State:NY
Mailing Address - Zip Code:11702-3027
Mailing Address - Country:US
Mailing Address - Phone:813-675-1281
Mailing Address - Fax:631-517-8007
Practice Address - Street 1:747 6TH AVE S
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33701-4509
Practice Address - Country:US
Practice Address - Phone:727-898-3647
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-14
Last Update Date:2008-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME00398682085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL06829690001Medicaid
FL62361Medicare ID - Type UnspecifiedMEDICARE#
FL06829690001Medicaid