Provider Demographics
NPI:1891556049
Name:LIVEACTIVE MULTISPECIALTY PHYSICIAN GROUP TAMPA LLC
Entity Type:Organization
Organization Name:LIVEACTIVE MULTISPECIALTY PHYSICIAN GROUP TAMPA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:SHANE
Authorized Official - Middle Name:
Authorized Official - Last Name:BRETHOWR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:913-549-3884
Mailing Address - Street 1:7111 W 151ST ST STE 303
Mailing Address - Street 2:
Mailing Address - City:OVERLAND PARK
Mailing Address - State:KS
Mailing Address - Zip Code:66223-2231
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1201 OAKBRIDGE PKWY
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33803-5945
Practice Address - Country:US
Practice Address - Phone:913-549-3884
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-01-16
Last Update Date:2024-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalistGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty