Provider Demographics
NPI:1528492287
Name:GREATER TAMPA BAY PHYSICIAN SPECIALISTS, LLC
Entity type:Organization
Organization Name:GREATER TAMPA BAY PHYSICIAN SPECIALISTS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GROUP VICE PRESIDENT/AO
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:TEDERICK
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-372-5372
Mailing Address - Street 1:2000 HEALTH PARK DR
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:TN
Mailing Address - Zip Code:37027-4525
Mailing Address - Country:US
Mailing Address - Phone:615-373-7600
Mailing Address - Fax:866-346-1426
Practice Address - Street 1:602 S AUDUBON AVE
Practice Address - Street 2:SUITE A
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33609-4217
Practice Address - Country:US
Practice Address - Phone:813-877-1415
Practice Address - Fax:817-877-7602
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-08-29
Last Update Date:2020-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
No2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Multi-Specialty