Provider Demographics
NPI:1811152366
Name:SAGO SUPERIOR MANAGEMENT INC
Entity type:Organization
Organization Name:SAGO SUPERIOR MANAGEMENT INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:SAFIYA
Authorized Official - Middle Name:A
Authorized Official - Last Name:GORDON
Authorized Official - Suffix:
Authorized Official - Credentials:ARNP
Authorized Official - Phone:727-320-7879
Mailing Address - Street 1:PO BOX 15485
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33733
Mailing Address - Country:US
Mailing Address - Phone:727-320-7879
Mailing Address - Fax:727-865-3242
Practice Address - Street 1:3040 36TH AVE S
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33712-3731
Practice Address - Country:US
Practice Address - Phone:727-320-7879
Practice Address - Fax:727-865-3242
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-24
Last Update Date:2008-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9176677363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL308592900Medicaid