Provider Demographics
NPI:1780877829
Name:SAMUEL GUBERNICK DO PA
Entity type:Organization
Organization Name:SAMUEL GUBERNICK DO PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:
Authorized Official - Last Name:GUBERNICK
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:727-530-0700
Mailing Address - Street 1:13145 66TH ST
Mailing Address - Street 2:
Mailing Address - City:LARGO
Mailing Address - State:FL
Mailing Address - Zip Code:33773-1812
Mailing Address - Country:US
Mailing Address - Phone:727-530-0700
Mailing Address - Fax:727-530-0777
Practice Address - Street 1:13145 66TH ST
Practice Address - Street 2:
Practice Address - City:LARGO
Practice Address - State:FL
Practice Address - Zip Code:33773-1812
Practice Address - Country:US
Practice Address - Phone:727-530-0700
Practice Address - Fax:727-530-0777
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-22
Last Update Date:2007-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS5550207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyGroup - Single Specialty