Provider Demographics
NPI:1508166786
Name:ST.JOHN'S MEDICAL CLINIC,PA
Entity Type:Organization
Organization Name:ST.JOHN'S MEDICAL CLINIC,PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHI-SHANG
Authorized Official - Middle Name:
Authorized Official - Last Name:CHEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:813-972-1282
Mailing Address - Street 1:12001 N NEBRASKA AVE
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33612-5343
Mailing Address - Country:US
Mailing Address - Phone:813-972-1282
Mailing Address - Fax:813-978-1677
Practice Address - Street 1:12001 N NEBRASKA AVE
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33612-5343
Practice Address - Country:US
Practice Address - Phone:813-972-1282
Practice Address - Fax:813-978-1677
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-22
Last Update Date:2010-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME41425208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty