Provider Demographics
NPI:1821340225
Name:ADVANCE TAMPA BAY FOOT MEDICAL, LLC
Entity Type:Organization
Organization Name:ADVANCE TAMPA BAY FOOT MEDICAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZE OFFICER
Authorized Official - Prefix:DR
Authorized Official - First Name:BENJAMIN
Authorized Official - Middle Name:Q
Authorized Official - Last Name:LE
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:813-831-3813
Mailing Address - Street 1:PO BOX 13485
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33681-3485
Mailing Address - Country:US
Mailing Address - Phone:813-831-3813
Mailing Address - Fax:
Practice Address - Street 1:3325 W GANDY BLVD
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33611-2931
Practice Address - Country:US
Practice Address - Phone:813-831-3813
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-09
Last Update Date:2017-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPO2234213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL007286100Medicaid
FLHD030AMedicare PIN
FL007286100Medicaid