Provider Demographics
NPI:1407990450
Name:GREGORY MCFADDEN MDPA
Entity Type:Organization
Organization Name:GREGORY MCFADDEN MDPA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:
Authorized Official - Last Name:MCFADDEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:813-767-6322
Mailing Address - Street 1:4308 ELLENVILLE PL
Mailing Address - Street 2:
Mailing Address - City:VALRICO
Mailing Address - State:FL
Mailing Address - Zip Code:33594-7147
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2901 W SAINT ISABEL ST
Practice Address - Street 2:SUITE #A3
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33607-6371
Practice Address - Country:US
Practice Address - Phone:813-874-2642
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-15
Last Update Date:2008-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME47498207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty