Provider Demographics
NPI:1699074716
Name:BLACKSTONE MEDICAL SERVICES LLC
Entity type:Organization
Organization Name:BLACKSTONE MEDICAL SERVICES LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:VICK
Authorized Official - Middle Name:
Authorized Official - Last Name:TIPNES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:813-831-2727
Mailing Address - Street 1:4030 HENDERSON BLVD STE 145
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33629-4940
Mailing Address - Country:US
Mailing Address - Phone:813-831-2727
Mailing Address - Fax:888-239-4616
Practice Address - Street 1:550 N REO ST STE 250
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33609-1039
Practice Address - Country:US
Practice Address - Phone:813-831-2727
Practice Address - Fax:888-239-4616
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-16
Last Update Date:2024-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS1200XAmbulatory Health Care FacilitiesClinic/CenterSleep Disorder Diagnostic
No293D00000XLaboratoriesPhysiological Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL017677000Medicaid