Basic Information
| Provider Information | |||||||||
| NPI: | 1033318365 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CLEARWATER EMERGENCY PHYSICIANS | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 7479 | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191017479 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8003550808 | ||||||||
| FaxNumber: | 6108342862 | ||||||||
| Practice Location | |||||||||
| Address1: | 300 PINELLAS ST | ||||||||
| Address2: | |||||||||
| City: | CLEARWATER | ||||||||
| State: | FL | ||||||||
| PostalCode: | 337563804 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7274618552 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/17/2007 | ||||||||
| LastUpdateDate: | 07/17/2007 | ||||||||
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| AuthorizedOfficialLastName: | PROVASNIK | ||||||||
| AuthorizedOfficialFirstName: | JENNIFER | ||||||||
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| AuthorizedOfficialTitleorPosition: | SUPERVISOR OF PROVIDER ENROLLMENT | ||||||||
| AuthorizedOfficialTelephone: | 8003550808 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 38109 | 01 | FL | BLUE SHIELD | OTHER |