Basic Information
| Provider Information | |||||||||
| NPI: | 1164010187 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MINIMALLY INVASIVE SURGICAL AFFILIATES, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 4706 | ||||||||
| Address2: | |||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336774706 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8132800202 | ||||||||
| FaxNumber: | 8132800203 | ||||||||
| Practice Location | |||||||||
| Address1: | 2715 N MACDILL AVE | ||||||||
| Address2: | |||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336072205 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8132800202 | ||||||||
| FaxNumber: | 8132800203 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/05/2021 | ||||||||
| LastUpdateDate: | 01/05/2021 | ||||||||
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| AuthorizedOfficialLastName: | HAMDAN | ||||||||
| AuthorizedOfficialFirstName: | TALAL | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 8132800202 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 01/05/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty |
ID Information
| ID | Type | State | Issuer | Description | PENDING | 01 | PENDING | OTHER |