Provider Demographics
NPI:1982816716
Name:ASTHMA ALLERGY AND IMMUNOLOGY OF TAMPA BAY PA
Entity Type:Organization
Organization Name:ASTHMA ALLERGY AND IMMUNOLOGY OF TAMPA BAY PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DIANA
Authorized Official - Middle Name:PATRICIA
Authorized Official - Last Name:MARTIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:813-873-1177
Mailing Address - Street 1:1918 WEST MARTIN LUTHER KING JR. BLVD
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33607-6504
Mailing Address - Country:US
Mailing Address - Phone:813-873-1177
Mailing Address - Fax:813-873-1166
Practice Address - Street 1:1918 W MARTIN L KING JR BLVD
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33607-6510
Practice Address - Country:US
Practice Address - Phone:813-873-1177
Practice Address - Fax:813-873-1166
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-04
Last Update Date:2012-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME88573261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL268116100Medicaid
I077253Medicare UPIN
FL268116100Medicaid
FLK5769AMedicare PIN