Provider Demographics
NPI:1972678084
Name:FLORIDA PHYSICAL MEDICINE, LLC
Entity Type:Organization
Organization Name:FLORIDA PHYSICAL MEDICINE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADM
Authorized Official - Prefix:
Authorized Official - First Name:TONJE
Authorized Official - Middle Name:
Authorized Official - Last Name:STEVENS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:727-518-2977
Mailing Address - Street 1:2200 W BAY DR
Mailing Address - Street 2:
Mailing Address - City:LARGO
Mailing Address - State:FL
Mailing Address - Zip Code:33770-1929
Mailing Address - Country:US
Mailing Address - Phone:727-518-2977
Mailing Address - Fax:
Practice Address - Street 1:5622 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33707-1718
Practice Address - Country:US
Practice Address - Phone:727-345-7900
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-22
Last Update Date:2007-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLK5987Medicare UPIN