Provider Demographics
NPI:1568805679
Name:CONCIERGE CARE TAMPA BAY LLC
Entity Type:Organization
Organization Name:CONCIERGE CARE TAMPA BAY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CHRIS
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:NUSSBAUM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:813-689-2961
Mailing Address - Street 1:510 VONDERBURG DR
Mailing Address - Street 2:SUITE 213
Mailing Address - City:BRANDON
Mailing Address - State:FL
Mailing Address - Zip Code:33511-5954
Mailing Address - Country:US
Mailing Address - Phone:813-689-2961
Mailing Address - Fax:813-685-2348
Practice Address - Street 1:510 VONDERBURG DR
Practice Address - Street 2:SUITE 213
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33511-5954
Practice Address - Country:US
Practice Address - Phone:813-689-2961
Practice Address - Fax:813-685-2348
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-04-09
Last Update Date:2013-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL49552208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLD51407Medicare UPIN