Provider Demographics
NPI:1497720700
Name:MEDICAL CENTER ON THE GULF LLC
Entity Type:Organization
Organization Name:MEDICAL CENTER ON THE GULF LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHAIRMAN
Authorized Official - Prefix:
Authorized Official - First Name:ANANDA
Authorized Official - Middle Name:
Authorized Official - Last Name:SOM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:727-738-0220
Mailing Address - Street 1:PO BOX 1921
Mailing Address - Street 2:
Mailing Address - City:DUNEDIN
Mailing Address - State:FL
Mailing Address - Zip Code:34697-1921
Mailing Address - Country:US
Mailing Address - Phone:727-738-0220
Mailing Address - Fax:727-734-7072
Practice Address - Street 1:30522 US 19 N STE 109
Practice Address - Street 2:
Practice Address - City:PALM HARBOR
Practice Address - State:FL
Practice Address - Zip Code:34684-4436
Practice Address - Country:US
Practice Address - Phone:727-738-0220
Practice Address - Fax:727-734-7072
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-21
Last Update Date:2015-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
110239219OtherRAILROAD MEDICARE
K8814OtherGRP #
P2746142OtherOXFORD HEALTH INSURANCE
244046OtherAVMED
FL254433400Medicaid
410972OtherTUFTS HEALTH PLAN
5306646OtherAETNA
1627837OtherFIRST HEALTH
213422OtherAMERIGROUP
3087332OtherCIGNA
43705OtherBLUE CROSS BLUE SHIELD
0407698OtherUNITED HEALTHCARE
244046OtherAVMED