Basic Information
| Provider Information | |||||||||
| NPI: | 1215988829 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CARROLLWOOD EMERGENCY PHYSICIANS PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12479 TELECOM DR | ||||||||
| Address2: | |||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336370913 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8139724199 | ||||||||
| FaxNumber: | 8139725753 | ||||||||
| Practice Location | |||||||||
| Address1: | 7171 N DALE MABRY HWY | ||||||||
| Address2: | |||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336142630 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8139322222 | ||||||||
| FaxNumber: | 8139725753 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/16/2006 | ||||||||
| LastUpdateDate: | 11/01/2007 | ||||||||
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| AuthorizedOfficialLastName: | LANDREVILLE | ||||||||
| AuthorizedOfficialFirstName: | ANDRE | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF OPERATING OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 8139724199 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 24275 | 01 | FL | BCBS OF FLORIDA | OTHER |