Provider Demographics
NPI:1700366010
Name:MARIE A BRISTER MD LLC
Entity Type:Organization
Organization Name:MARIE A BRISTER MD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARIE
Authorized Official - Middle Name:
Authorized Official - Last Name:BRISTER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:813-229-1924
Mailing Address - Street 1:508 W DR MARTIN LUTHER KING JR BLVD STE A
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33603-3415
Mailing Address - Country:US
Mailing Address - Phone:813-229-1924
Mailing Address - Fax:
Practice Address - Street 1:508 W DR MARTIN LUTHER KING JR BLVD STE A
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33603
Practice Address - Country:US
Practice Address - Phone:813-229-1924
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-08-16
Last Update Date:2018-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME118349207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty