Provider Demographics
NPI:1124354410
Name:DRS CLACK SPENCER WHITE & MCCORMACK PA
Entity type:Organization
Organization Name:DRS CLACK SPENCER WHITE & MCCORMACK PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:M
Authorized Official - Last Name:MCCORMACK
Authorized Official - Suffix:
Authorized Official - Credentials:MD, PHD
Authorized Official - Phone:941-362-8900
Mailing Address - Street 1:2001 WEBBER ST
Mailing Address - Street 2:
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34239-5237
Mailing Address - Country:US
Mailing Address - Phone:941-362-8900
Mailing Address - Fax:941-362-8987
Practice Address - Street 1:2001 WEBBER ST
Practice Address - Street 2:
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34239-5237
Practice Address - Country:US
Practice Address - Phone:941-362-8900
Practice Address - Fax:941-362-8987
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DRS CLACK SPENCER WHITE & MCCORMACK PA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-10-22
Last Update Date:2017-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLLAB800000813291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLL8218OtherBCBS OF FLORIDA
FLLAB 80000813OtherAHCA CLINICAL LABORATORY LICENSE
FL10D0296120OtherCMS CLIA CERTIFICATION