Provider Demographics
NPI:1265248579
Name:DOCTOR DOCTOR ON-CALL
Entity type:Organization
Organization Name:DOCTOR DOCTOR ON-CALL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:HENRIA
Authorized Official - Middle Name:M
Authorized Official - Last Name:FAIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD, DPT, ATC
Authorized Official - Phone:813-743-4383
Mailing Address - Street 1:PO BOX 75496
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33675-0496
Mailing Address - Country:US
Mailing Address - Phone:813-597-1758
Mailing Address - Fax:
Practice Address - Street 1:2314 E 22ND AVE
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33605-2067
Practice Address - Country:US
Practice Address - Phone:813-597-1758
Practice Address - Fax:813-706-6612
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-12-10
Last Update Date:2024-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical TherapyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL121064700Medicaid