Provider Demographics
NPI:1700087822
Name:OPHTHALMIC LABORATORY ST JOSEPHS HOSPITAL INC
Entity Type:Organization
Organization Name:OPHTHALMIC LABORATORY ST JOSEPHS HOSPITAL INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ORTHOPTIST SECRETARY TREASURER
Authorized Official - Prefix:MRS
Authorized Official - First Name:CLARA
Authorized Official - Middle Name:CHRIST
Authorized Official - Last Name:BERRYMAN
Authorized Official - Suffix:
Authorized Official - Credentials:CO
Authorized Official - Phone:813-872-0480
Mailing Address - Street 1:2608 W AZEELE ST
Mailing Address - Street 2:#3
Mailing Address - City:TAMAP
Mailing Address - State:FL
Mailing Address - Zip Code:33609
Mailing Address - Country:US
Mailing Address - Phone:813-872-0480
Mailing Address - Fax:813-872-0480
Practice Address - Street 1:2608 W AZEELE ST
Practice Address - Street 2:#3
Practice Address - City:TAMAP
Practice Address - State:FL
Practice Address - Zip Code:33609
Practice Address - Country:US
Practice Address - Phone:813-872-0480
Practice Address - Fax:813-872-0480
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-29
Last Update Date:2007-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL72223Medicare ID - Type Unspecified