Provider Demographics
NPI:1346212370
Name:BLUESTONE PHYSICIAN SERVICES SOUTHEAST LLC
Entity Type:Organization
Organization Name:BLUESTONE PHYSICIAN SERVICES SOUTHEAST LLC
Other - Org Name:BLUESTONE PHYSICIAN SERVICES FLORIDA, LLC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DIANA
Authorized Official - Middle Name:
Authorized Official - Last Name:BERNARD
Authorized Official - Suffix:I
Authorized Official - Credentials:
Authorized Official - Phone:813-259-1013
Mailing Address - Street 1:10150 HIGHLAND MANOR DR STE 205
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33610-9727
Mailing Address - Country:US
Mailing Address - Phone:813-259-1013
Mailing Address - Fax:813-254-0396
Practice Address - Street 1:10150 HIGHLAND MANOR DR STE 205
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33610-9727
Practice Address - Country:US
Practice Address - Phone:813-259-1013
Practice Address - Fax:813-254-0396
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-03
Last Update Date:2024-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL015006200Medicaid
FL34388OtherBC/BS
FLCK5239OtherRAILROAD MEDICARE
FL34388OtherBC/BS