Provider Demographics
NPI:1114295698
Name:MPM CARDIOLOGY SERVICES LLC
Entity type:Organization
Organization Name:MPM CARDIOLOGY SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:GLENN
Authorized Official - Middle Name:D
Authorized Official - Last Name:WATERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:727-532-1355
Mailing Address - Street 1:PO BOX 9200
Mailing Address - Street 2:
Mailing Address - City:PALM HARBOR
Mailing Address - State:FL
Mailing Address - Zip Code:34682-9200
Mailing Address - Country:US
Mailing Address - Phone:727-789-3179
Mailing Address - Fax:727-781-1315
Practice Address - Street 1:300 PARK PLACE BLVD
Practice Address - Street 2:SUITE 170
Practice Address - City:CLEARWATER
Practice Address - State:FL
Practice Address - Zip Code:33759-4932
Practice Address - Country:US
Practice Address - Phone:727-532-0002
Practice Address - Fax:727-266-4928
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-12
Last Update Date:2015-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL008209100Medicaid
FLGY612AMedicare PIN
FLGY612BMedicare PIN