Provider Demographics
NPI:1497776678
Name:PASADENA ENT PA
Entity Type:Organization
Organization Name:PASADENA ENT PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ROY
Authorized Official - Middle Name:
Authorized Official - Last Name:SPENCE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:727-341-0551
Mailing Address - Street 1:6827 FIRST AVENUE SOUTH
Mailing Address - Street 2:SUITE 100
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33707-4516
Mailing Address - Country:US
Mailing Address - Phone:727-341-0551
Mailing Address - Fax:727-341-0332
Practice Address - Street 1:6827 FIRST AVENUE SOUTH
Practice Address - Street 2:SUITE 100
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33707-4516
Practice Address - Country:US
Practice Address - Phone:727-341-0551
Practice Address - Fax:727-341-0332
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-22
Last Update Date:2014-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME82762174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL261879600Medicaid
FLH40251Medicare UPIN
FL01150ZMedicare ID - Type UnspecifiedMEDICARE #