Provider Demographics
NPI:1942555180
Name:MCILWAIN MEDICAL GROUP, PA
Entity Type:Organization
Organization Name:MCILWAIN MEDICAL GROUP, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:HARRIS
Authorized Official - Middle Name:
Authorized Official - Last Name:MCILWAIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:813-971-5550
Mailing Address - Street 1:13801 BRUCE B DOWNS BLVD
Mailing Address - Street 2:SUITE 406
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33613-3946
Mailing Address - Country:US
Mailing Address - Phone:813-971-5550
Mailing Address - Fax:813-903-1070
Practice Address - Street 1:4700 N HABANA AVE
Practice Address - Street 2:SUITE 201
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33614-7160
Practice Address - Country:US
Practice Address - Phone:813-879-5485
Practice Address - Fax:813-870-1781
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-13
Last Update Date:2012-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME26737207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatologyGroup - Multi-Specialty