Provider Demographics
NPI:1639318637
Name:GERALD A NIEDZWIECKI MD PA
Entity Type:Organization
Organization Name:GERALD A NIEDZWIECKI MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/SHAREHOLDER
Authorized Official - Prefix:DR
Authorized Official - First Name:GERALD
Authorized Official - Middle Name:ANTHONY
Authorized Official - Last Name:NIEDZWIECKI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:727-791-7300
Mailing Address - Street 1:2730 N MCMULLEN BOOTH RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33761-3302
Mailing Address - Country:US
Mailing Address - Phone:727-791-7300
Mailing Address - Fax:727-723-9010
Practice Address - Street 1:2730 N MCMULLEN BOOTH RD
Practice Address - Street 2:SUITE 203
Practice Address - City:CLEARWATER
Practice Address - State:FL
Practice Address - Zip Code:33761-3302
Practice Address - Country:US
Practice Address - Phone:727-286-8929
Practice Address - Fax:727-286-8933
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-13
Last Update Date:2015-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME814742085N0700X, 2085R0202X
FLME00706492085R0202X, 2085R0204X, 2085U0001X
FLPAT9104325363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional RadiologyGroup - Multi-Specialty
No2085N0700XAllopathic & Osteopathic PhysiciansRadiologyNeuroradiologyGroup - Multi-Specialty
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Multi-Specialty
No2085U0001XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic UltrasoundGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL203364OtherAVMED
FL300123717OtherRAILROAD MEDICARE
FL31439OtherBCBS
FL4593565OtherAETNA PPO
FL1600774OtherUNITED HEALTHCARE
FL220039OtherAMERIGROUP
FL250195300Medicaid
FL2648373OtherAETNA HMO
FL250195300Medicaid
FL1600774OtherUNITED HEALTHCARE