Provider Demographics
NPI:1588718860
Name:SOUTH TAMPA MEDICAL GROUP PA
Entity type:Organization
Organization Name:SOUTH TAMPA MEDICAL GROUP PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER PHYSICAN
Authorized Official - Prefix:
Authorized Official - First Name:HENRY
Authorized Official - Middle Name:J
Authorized Official - Last Name:WEISS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:352-516-8991
Mailing Address - Street 1:340 SAPPHIRE LAKE DR UNIT 101
Mailing Address - Street 2:
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34209-3445
Mailing Address - Country:US
Mailing Address - Phone:352-516-8991
Mailing Address - Fax:954-206-0526
Practice Address - Street 1:206 2ND ST E
Practice Address - Street 2:
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34208-1042
Practice Address - Country:US
Practice Address - Phone:941-746-5111
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-23
Last Update Date:2022-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLO9089OtherMEDICARE
39161Medicare PIN