Provider Demographics
NPI:1689682247
Name:ST. PETERSBURG ENDOSCOPY CENTER LLC
Entity Type:Organization
Organization Name:ST. PETERSBURG ENDOSCOPY CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CHETAN
Authorized Official - Middle Name:K
Authorized Official - Last Name:DESAI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:727-820-7500
Mailing Address - Street 1:560 JACKSON STREET NORTH
Mailing Address - Street 2:SUITE 200
Mailing Address - City:ST. PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33705-1449
Mailing Address - Country:US
Mailing Address - Phone:727-820-7500
Mailing Address - Fax:727-820-6333
Practice Address - Street 1:560 JACKSON STREET NORTH
Practice Address - Street 2:SUITE 200
Practice Address - City:ST. PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33705-1449
Practice Address - Country:US
Practice Address - Phone:727-820-7500
Practice Address - Fax:727-820-6333
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-03
Last Update Date:2012-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1247261QA1903X
FL14960618261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL076202400Medicaid
FL076202400Medicaid