Provider Demographics
NPI:1790060333
Name:ED MEDICAL THERAPY CENTER, INC.
Entity Type:Organization
Organization Name:ED MEDICAL THERAPY CENTER, INC.
Other - Org Name:ED MEDICAL THERAPY CENTER, INC.
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:JANIS
Authorized Official - Middle Name:
Authorized Official - Last Name:GOMEZ
Authorized Official - Suffix:X
Authorized Official - Credentials:PRESIDENT
Authorized Official - Phone:813-407-1591
Mailing Address - Street 1:4311 W WATERS AVE
Mailing Address - Street 2:SUITE 205
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33614
Mailing Address - Country:US
Mailing Address - Phone:813-407-1591
Mailing Address - Fax:
Practice Address - Street 1:4311 W WATERS AVE
Practice Address - Street 2:SUIT #205
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33614
Practice Address - Country:US
Practice Address - Phone:813-407-1591
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-14
Last Update Date:2015-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FMHCC9274208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty