Provider Demographics
NPI:1699729616
Name:TIFFANY SQUARE FAMILY PRACTICE P A
Entity type:Organization
Organization Name:TIFFANY SQUARE FAMILY PRACTICE P A
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:PHILIP
Authorized Official - Last Name:NIMBARGI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:941-474-8154
Mailing Address - Street 1:2828 S MCCALL RD
Mailing Address - Street 2:STE 21
Mailing Address - City:ENGLEWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:34224
Mailing Address - Country:US
Mailing Address - Phone:941-474-8154
Mailing Address - Fax:941-473-3583
Practice Address - Street 1:2828 S MCCALL RD
Practice Address - Street 2:STE 21
Practice Address - City:ENGLEWOOD
Practice Address - State:FL
Practice Address - Zip Code:34224
Practice Address - Country:US
Practice Address - Phone:941-474-8154
Practice Address - Fax:941-473-3583
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-22
Last Update Date:2008-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLK1992Medicare PIN