Provider Demographics
NPI:1922046846
Name:FAMILY MEDICAL CENTERS OF TAMPA BAY PA
Entity Type:Organization
Organization Name:FAMILY MEDICAL CENTERS OF TAMPA BAY PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ALAN
Authorized Official - Middle Name:J
Authorized Official - Last Name:IEZZI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:813-963-3124
Mailing Address - Street 1:15511 N FLORIDA AVE
Mailing Address - Street 2:SUITE D
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33613-1263
Mailing Address - Country:US
Mailing Address - Phone:813-963-3124
Mailing Address - Fax:813-269-7945
Practice Address - Street 1:15511 N FLORIDA AVE
Practice Address - Street 2:SUITE 401
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33613-1220
Practice Address - Country:US
Practice Address - Phone:813-963-3124
Practice Address - Fax:813-269-7945
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-03
Last Update Date:2011-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL0046451207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLK2637Medicare PIN