Provider Demographics
NPI:1700256450
Name:MEDI MELBOURNE LLC
Entity type:Organization
Organization Name:MEDI MELBOURNE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:K
Authorized Official - Last Name:WILLETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:813-245-5305
Mailing Address - Street 1:412 E MADISON ST
Mailing Address - Street 2:SUITE 1100
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33602-4601
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7630 N WICKHAM RD
Practice Address - Street 2:SUITE 104
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32940-8257
Practice Address - Country:US
Practice Address - Phone:321-610-7982
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-06
Last Update Date:2016-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty