Provider Demographics
NPI:1720390875
Name:ROGER C. BRAINARD, MD, PA
Entity Type:Organization
Organization Name:ROGER C. BRAINARD, MD, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TINA
Authorized Official - Middle Name:R
Authorized Official - Last Name:PENROD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:813-876-2324
Mailing Address - Street 1:3006 W AZEELE ST
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33609-3139
Mailing Address - Country:US
Mailing Address - Phone:813-874-3006
Mailing Address - Fax:813-876-6258
Practice Address - Street 1:3006 W AZEELE ST
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33609-3139
Practice Address - Country:US
Practice Address - Phone:813-874-3006
Practice Address - Fax:813-876-6258
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-06
Last Update Date:2010-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME34885174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLD85504Medicare UPIN
FL30199Medicare PIN