Basic Information
| Provider Information | |||||||||
| NPI: | 1093797813 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BARRETT | ||||||||
| FirstName: | STEVEN | ||||||||
| MiddleName: | MARK | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2075 TOWN CTR BLVD | ||||||||
| Address2: | |||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328376803 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8636807000 | ||||||||
| FaxNumber: | 8636807420 | ||||||||
| Practice Location | |||||||||
| Address1: | 1600 LAKELAND HILLS BLVD | ||||||||
| Address2: | |||||||||
| City: | LAKELAND | ||||||||
| State: | FL | ||||||||
| PostalCode: | 338053029 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8636807000 | ||||||||
| FaxNumber: | 8636807420 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/17/2005 | ||||||||
| LastUpdateDate: | 05/24/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207PE0004X | ME75196 | FL | N | Allopathic & Osteopathic Physicians | Emergency Medicine | Emergency Medical Services | 207P00000X | ME75196 | FL | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 254092400 | 05 | FL | MEDICAID |