Provider Demographics
NPI:1578732889
Name:LARGO PHYSICIAN GROUP, LLC
Entity Type:Organization
Organization Name:LARGO PHYSICIAN GROUP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIVISION VP/AO
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:TEDRICK
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-372-3375
Mailing Address - Street 1:2000 HEALTH PARK DR
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:TN
Mailing Address - Zip Code:37027-4525
Mailing Address - Country:US
Mailing Address - Phone:615-373-7600
Mailing Address - Fax:866-346-1426
Practice Address - Street 1:11373 CORTEZ BLVD STE 408
Practice Address - Street 2:
Practice Address - City:BROOKSVILLE
Practice Address - State:FL
Practice Address - Zip Code:34613-5406
Practice Address - Country:US
Practice Address - Phone:352-592-7310
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-21
Last Update Date:2020-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL72062AOtherBCBS FL-WALSINGHAM
FL000757301OtherMEDICAID-WALSINGHAM LOCATION
FL000757303OtherMEDICAID-BARDMOOR LOCATION
FL72062BOtherBCBS FL--38TH AVE N.
FL000757300OtherMEDICAID --INDIAN ROCKS LOCATION
FL72062OtherBCBS FL--INDIAN ROCKS
FL76062COtherBCBS FL-- BARDMOOR
FL76062COtherBCBS FL-- BARDMOOR