Provider Demographics
NPI:1720400054
Name:PINELLAS NEUROINTERVENTIONAL CONSULTANTS, PA
Entity Type:Organization
Organization Name:PINELLAS NEUROINTERVENTIONAL CONSULTANTS, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:ELLIS
Authorized Official - Middle Name:B
Authorized Official - Last Name:NORSOPH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:813-899-6220
Mailing Address - Street 1:PO BOX 23057
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33623-3057
Mailing Address - Country:US
Mailing Address - Phone:813-899-6220
Mailing Address - Fax:813-985-8006
Practice Address - Street 1:701 6TH STREET SOUTH
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33701-4814
Practice Address - Country:US
Practice Address - Phone:727-823-1234
Practice Address - Fax:813-985-8006
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-06
Last Update Date:2015-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Multi-Specialty
No2085N0700XAllopathic & Osteopathic PhysiciansRadiologyNeuroradiologyGroup - Multi-Specialty
No2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional RadiologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL010458400Medicaid
FL010458400Medicaid