Provider Demographics
NPI:1982150348
Name:CARROLLWOOD MEDICAL GROUP, LLC.
Entity Type:Organization
Organization Name:CARROLLWOOD MEDICAL GROUP, LLC.
Other - Org Name:REVELLO MEDICAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:ANTONIO
Authorized Official - Middle Name:
Authorized Official - Last Name:CALVO
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:813-888-8215
Mailing Address - Street 1:5901 WEBB RD
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33615-3219
Mailing Address - Country:US
Mailing Address - Phone:813-888-8215
Mailing Address - Fax:813-885-5398
Practice Address - Street 1:10213 LAKE CARROLL WAY
Practice Address - Street 2:STE D
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33618-4402
Practice Address - Country:US
Practice Address - Phone:813-888-8215
Practice Address - Fax:813-885-5398
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-26
Last Update Date:2016-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center