Provider Demographics
NPI:1104441617
Name:PROMEDTC, LLC
Entity type:Organization
Organization Name:PROMEDTC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:TYMUR
Authorized Official - Middle Name:
Authorized Official - Last Name:CHEPI-IPA
Authorized Official - Suffix:
Authorized Official - Credentials:APRN-C
Authorized Official - Phone:718-666-8759
Mailing Address - Street 1:777 N ASHLEY DR UNIT 1815
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33602-4373
Mailing Address - Country:US
Mailing Address - Phone:718-666-8759
Mailing Address - Fax:
Practice Address - Street 1:3109 LITHIA PINECREST RD
Practice Address - Street 2:
Practice Address - City:VALRICO
Practice Address - State:FL
Practice Address - Zip Code:33596-5632
Practice Address - Country:US
Practice Address - Phone:718-666-8759
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-06-10
Last Update Date:2020-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1548623432OtherNPI