Provider Demographics
| NPI: | 1912375742 |
|---|---|
| Name: | SELECT PHYSICIANS ALLIANCE |
| Entity Type: | Organization |
| Organization Name: | SELECT PHYSICIANS ALLIANCE |
| Other - Org Name: | |
| Other - Org Type: | |
| Authorized Official - Title/Position: | COO |
| Authorized Official - Prefix: | |
| Authorized Official - First Name: | SHERYL |
| Authorized Official - Middle Name: | A |
| Authorized Official - Last Name: | WATTS |
| Authorized Official - Suffix: | |
| Authorized Official - Credentials: | |
| Authorized Official - Phone: | 813-571-7184 |
| Mailing Address - Street 1: | 10002 PRINCESS PALM AVE |
| Mailing Address - Street 2: | STE 332 |
| Mailing Address - City: | TAMPA |
| Mailing Address - State: | FL |
| Mailing Address - Zip Code: | 33619-8327 |
| Mailing Address - Country: | US |
| Mailing Address - Phone: | 813-571-7184 |
| Mailing Address - Fax: | 813-654-4695 |
| Practice Address - Street 1: | 10002 PRINCESS PALM AVE STE 332 |
| Practice Address - Street 2: | |
| Practice Address - City: | TAMPA |
| Practice Address - State: | FL |
| Practice Address - Zip Code: | 33619 |
| Practice Address - Country: | US |
| Practice Address - Phone: | 813-571-7184 |
| Practice Address - Fax: | 813-654-4695 |
| EIN: | <UNAVAIL> |
| Is Organization Subpart?: | Yes |
| Parent Organization LBN: | SELECT PHYSICIANS ALLIANCE |
| Parent Organization TIN: | <UNAVAIL> |
| Enumeration Date: | 2015-09-10 |
| Last Update Date: | 2019-03-29 |
| Deactivation Date: | |
| Deactivation Code: | |
| Reactivation Date: |
Provider Taxonomies
| Primary? | Code | Type | Classification | Specialization | Group |
|---|---|---|---|---|---|
| Yes | 207Y00000X | Allopathic & Osteopathic Physicians | Otolaryngology | Group - Multi-Specialty | |
| No | 207YP0228X | Allopathic & Osteopathic Physicians | Otolaryngology | Pediatric Otolaryngology | Group - Multi-Specialty |
| No | 207YS0012X | Allopathic & Osteopathic Physicians | Otolaryngology | Sleep Medicine | Group - Multi-Specialty |
| No | 207YS0123X | Allopathic & Osteopathic Physicians | Otolaryngology | Facial Plastic Surgery | Group - Multi-Specialty |
| No | 207YX0007X | Allopathic & Osteopathic Physicians | Otolaryngology | Plastic Surgery within the Head & Neck | Group - Multi-Specialty |
| No | 207YX0602X | Allopathic & Osteopathic Physicians | Otolaryngology | Otolaryngic Allergy | Group - Multi-Specialty |
| No | 207YX0901X | Allopathic & Osteopathic Physicians | Otolaryngology | Otology & Neurotology | Group - Multi-Specialty |
| No | 207YX0905X | Allopathic & Osteopathic Physicians | Otolaryngology | Otolaryngology/Facial Plastic Surgery | Group - Multi-Specialty |
| No | 208100000X | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | Group - Multi-Specialty | |
| No | 231H00000X | Speech, Language and Hearing Service Providers | Audiologist | Group - Multi-Specialty | |
| No | 235Z00000X | Speech, Language and Hearing Service Providers | Speech-Language Pathologist | Group - Multi-Specialty | |
| No | 237600000X | Speech, Language and Hearing Service Providers | Audiologist-Hearing Aid Fitter | Group - Multi-Specialty |
Provider Identifiers
| State | Identifier ID | ID Type | Issuer |
|---|---|---|---|
| FL | 004140000 | Medicaid | |
| FL | 004140000 | Medicaid | |
| FL | FM218A | Medicare UPIN |
