Provider Demographics
NPI:1962843029
Name:DALEY AND ASSOCIATES PRIMEMED OF TAMPA BAY LLC
Entity Type:Organization
Organization Name:DALEY AND ASSOCIATES PRIMEMED OF TAMPA BAY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MPM SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:JOSIE
Authorized Official - Middle Name:A
Authorized Official - Last Name:WALTERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:302-233-2532
Mailing Address - Street 1:300 RIVERSIDE DR E
Mailing Address - Street 2:STE 2600
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34208-1008
Mailing Address - Country:US
Mailing Address - Phone:941-251-4933
Mailing Address - Fax:941-251-4934
Practice Address - Street 1:300 RIVERSIDE DR E
Practice Address - Street 2:STE 2600
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34208-1008
Practice Address - Country:US
Practice Address - Phone:941-251-4933
Practice Address - Fax:941-251-4934
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-07-17
Last Update Date:2013-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME92581207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL273870800Medicaid
FLI39571Medicare UPIN
FLU5781ZMedicare PIN