Provider Demographics
NPI:1568656429
Name:WEST COAST MEDICINE OF TAMPA BAY, LLC
Entity Type:Organization
Organization Name:WEST COAST MEDICINE OF TAMPA BAY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:GEORGE
Authorized Official - Last Name:KANTZLER
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:727-458-3011
Mailing Address - Street 1:PO BOX 1619
Mailing Address - Street 2:
Mailing Address - City:LARGO
Mailing Address - State:FL
Mailing Address - Zip Code:33779-1619
Mailing Address - Country:US
Mailing Address - Phone:727-458-3011
Mailing Address - Fax:
Practice Address - Street 1:1155 S DALE MABRY HWY
Practice Address - Street 2:#19
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33629-5035
Practice Address - Country:US
Practice Address - Phone:727-458-3011
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-04
Last Update Date:2012-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS5165207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLE32311Medicare UPIN
FLK8834Medicare PIN