Basic Information
| Provider Information | |||||||||
| NPI: | 1225030620 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MICHELMAN | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | S | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1201 5TH AVE N | ||||||||
| Address2: | SUITE 505 | ||||||||
| City: | ST PETERSBURG | ||||||||
| State: | FL | ||||||||
| PostalCode: | 337051455 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7278218194 | ||||||||
| FaxNumber: | 7275028861 | ||||||||
| Practice Location | |||||||||
| Address1: | 303 PINELLAS ST | ||||||||
| Address2: | SUITE 330 | ||||||||
| City: | CLEARWATER | ||||||||
| State: | FL | ||||||||
| PostalCode: | 337563809 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7274478100 | ||||||||
| FaxNumber: | 7274612603 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/15/2005 | ||||||||
| LastUpdateDate: | 01/05/2011 | ||||||||
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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 | 207RH0000X | ME21517 | FL | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology |
ID Information
| ID | Type | State | Issuer | Description | 326383900 | 05 | FL | MEDICAID | 830003872 | 01 | FL | MEDICARE RR | OTHER | 78042 | 01 | BLUE CROSS / BLUE SHIELD | OTHER |