Provider Demographics
NPI:1265613244
Name:KENNETH A. NEIFIELD, M.D., P.L.
Entity type:Organization
Organization Name:KENNETH A. NEIFIELD, M.D., P.L.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:TATIANA
Authorized Official - Middle Name:
Authorized Official - Last Name:CHUMBLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:727-498-8699
Mailing Address - Street 1:2191 9TH AVE N
Mailing Address - Street 2:SUITE 110
Mailing Address - City:SAINT PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33713-7147
Mailing Address - Country:US
Mailing Address - Phone:727-820-7778
Mailing Address - Fax:727-820-7779
Practice Address - Street 1:2191 9TH AVE N
Practice Address - Street 2:SUITE 110
Practice Address - City:SAINT PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33713-7147
Practice Address - Country:US
Practice Address - Phone:727-820-7778
Practice Address - Fax:727-820-7779
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-19
Last Update Date:2012-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME64972207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL373852300Medicaid
FL23516XMedicare PIN
FL373852300Medicaid