Provider Demographics
NPI:1881063436
Name:ALL MEDICAL GROUP OF TAMPA BAY,LLC
Entity type:Organization
Organization Name:ALL MEDICAL GROUP OF TAMPA BAY,LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:O
Authorized Official - Prefix:
Authorized Official - First Name:S
Authorized Official - Middle Name:
Authorized Official - Last Name:S
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:813-765-1930
Mailing Address - Street 1:3413 S KINGS AVE
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:FL
Mailing Address - Zip Code:33511-7780
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3413 S KINGS AVE
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33511-7780
Practice Address - Country:US
Practice Address - Phone:888-888-8888
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-24
Last Update Date:2016-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
305R00000X
FLME119290207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLIA903ZMedicaid