Provider Demographics
NPI:1356529929
Name:MCGOMEZ, ROSE MARIE
Entity type:Individual
Prefix:
First Name:ROSE MARIE
Middle Name:
Last Name:MCGOMEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8710 W HILLSBOROUGH AVE
Mailing Address - Street 2:#154
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33615-3705
Mailing Address - Country:US
Mailing Address - Phone:813-774-3922
Mailing Address - Fax:206-338-3962
Practice Address - Street 1:8710 W HILLSBOROUGH AVE
Practice Address - Street 2:STE 154
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33615-3705
Practice Address - Country:US
Practice Address - Phone:813-774-3922
Practice Address - Fax:206-338-3962
Is Sole Proprietor?:No
Enumeration Date:2008-02-06
Last Update Date:2008-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL693104900Medicaid