Provider Demographics
NPI:1215988829
Name:CARROLLWOOD EMERGENCY PHYSICIANS PA
Entity type:Organization
Organization Name:CARROLLWOOD EMERGENCY PHYSICIANS PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF OPERATING OFFICER
Authorized Official - Prefix:DR
Authorized Official - First Name:ANDRE
Authorized Official - Middle Name:R
Authorized Official - Last Name:LANDREVILLE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:813-972-4199
Mailing Address - Street 1:12479 TELECOM DR
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33637-0913
Mailing Address - Country:US
Mailing Address - Phone:813-972-4199
Mailing Address - Fax:813-972-5753
Practice Address - Street 1:7171 N DALE MABRY HWY
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33614-2630
Practice Address - Country:US
Practice Address - Phone:813-932-2222
Practice Address - Fax:813-972-5753
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-16
Last Update Date:2007-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL24275OtherBCBS OF FLORIDA
FL24275Medicare PIN