Provider Demographics
NPI:1386700797
Name:EXPRESS CARE OF TAMPA BAY, LLC
Entity type:Organization
Organization Name:EXPRESS CARE OF TAMPA BAY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KHAWAJA
Authorized Official - Middle Name:A
Authorized Official - Last Name:RAHMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:813-690-7589
Mailing Address - Street 1:6015 REX HALL LN
Mailing Address - Street 2:
Mailing Address - City:APOLLO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33572-2657
Mailing Address - Country:US
Mailing Address - Phone:813-641-0068
Mailing Address - Fax:813-645-3816
Practice Address - Street 1:6015 REX HALL LN
Practice Address - Street 2:
Practice Address - City:APOLLO BEACH
Practice Address - State:FL
Practice Address - Zip Code:33572-2657
Practice Address - Country:US
Practice Address - Phone:813-641-0068
Practice Address - Fax:813-645-3816
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-29
Last Update Date:2011-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0071027207R00000X
FLME0079013207R00000X
FLME71027207RC0200X
FLME79013207RC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL10560801OtherCITRUS GROUP UC
FL608813300OtherDEPT OF LABOR FACILITY
FLB903UOtherBCBS GROUP UC
FLDB9962OtherRR MCARE GROUP
FL269227900Medicaid
FLB903UOtherBCBS GROUP UC
FLG43463Medicare UPIN
FLK5624Medicare ID - Type Unspecified
FL=========OtherTAX ID #
FL608813300OtherDEPT OF LABOR FACILITY