Provider Demographics
NPI:1619460730
Name:PREMIER INTERNAL MEDICINE OF TAMPA LLC
Entity Type:Organization
Organization Name:PREMIER INTERNAL MEDICINE OF TAMPA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JANUSZ
Authorized Official - Middle Name:
Authorized Official - Last Name:MADEJ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:813-930-7877
Mailing Address - Street 1:4913 VAN DYKE RD
Mailing Address - Street 2:
Mailing Address - City:LUTZ
Mailing Address - State:FL
Mailing Address - Zip Code:33558-4813
Mailing Address - Country:US
Mailing Address - Phone:813-930-7877
Mailing Address - Fax:
Practice Address - Street 1:4913 VAN DYKE RD
Practice Address - Street 2:
Practice Address - City:LUTZ
Practice Address - State:FL
Practice Address - Zip Code:33558-4813
Practice Address - Country:US
Practice Address - Phone:813-930-7877
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-06-13
Last Update Date:2018-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty