Provider Demographics
NPI:1205061140
Name:SUNCOAST MEDICAL CLINIC LLC
Entity type:Organization
Organization Name:SUNCOAST MEDICAL CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:L
Authorized Official - Last Name:ETTEL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:727-894-1818
Mailing Address - Street 1:601 7TH ST S
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33701-4704
Mailing Address - Country:US
Mailing Address - Phone:727-894-1818
Mailing Address - Fax:727-824-3132
Practice Address - Street 1:601 7TH ST S
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33701-4704
Practice Address - Country:US
Practice Address - Phone:727-894-1818
Practice Address - Fax:727-824-3132
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SUNCOAST MEDICAL CLINIC LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-05-21
Last Update Date:2009-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLY901QOtherBCBS