Provider Demographics
NPI:1477641959
Name:ST. MARY'S NEUROLOGY CENTER, INC.
Entity Type:Organization
Organization Name:ST. MARY'S NEUROLOGY CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:REENA
Authorized Official - Middle Name:J
Authorized Official - Last Name:KAVILAVEETTIL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:813-972-5414
Mailing Address - Street 1:15267 AMBERLY DR
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33647-2155
Mailing Address - Country:US
Mailing Address - Phone:813-972-5414
Mailing Address - Fax:813-972-5413
Practice Address - Street 1:15267 AMBERLY DR
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33647-2155
Practice Address - Country:US
Practice Address - Phone:813-972-5414
Practice Address - Fax:813-972-5413
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-10
Last Update Date:2015-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME927652084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLQ0392Medicare PIN
I37567Medicare UPIN
FLQ0392Medicare PIN