Basic Information
| Provider Information | |||||||||
| NPI: | 1023238284 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MCBATH MEDICAL CENTER PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 13933 17TH ST | ||||||||
| Address2: | STE: 101 | ||||||||
| City: | DADE CITY | ||||||||
| State: | FL | ||||||||
| PostalCode: | 335254603 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3525676763 | ||||||||
| FaxNumber: | 3525671358 | ||||||||
| Practice Location | |||||||||
| Address1: | 13933 17TH ST | ||||||||
| Address2: | STE: 101 | ||||||||
| City: | DADE CITY | ||||||||
| State: | FL | ||||||||
| PostalCode: | 335254603 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3525676763 | ||||||||
| FaxNumber: | 3525671358 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/27/2007 | ||||||||
| LastUpdateDate: | 11/30/2009 | ||||||||
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| AuthorizedOfficialLastName: | MCBATH | ||||||||
| AuthorizedOfficialFirstName: | DANIEL | ||||||||
| AuthorizedOfficialMiddleName: | PHILIP | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER PHYSICIAN | ||||||||
| AuthorizedOfficialTelephone: | 3525676763 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | D.O. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | FC1011371 | FL | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | OS6111 | FL | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 278099200 | 05 | FL | MEDICAID | 34296 | 01 | FL | BCBS | OTHER |