Basic Information
| Provider Information | |||||||||
| NPI: | 1275200248 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | INNOVACARE CENTRAL FLORIDA PHYSICIANS, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1111 7TH AVE N STE 107 | ||||||||
| Address2: | |||||||||
| City: | SAINT PETERSBURG | ||||||||
| State: | FL | ||||||||
| PostalCode: | 337051348 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7278941661 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1111 7TH AVE N STE 107 | ||||||||
| Address2: | |||||||||
| City: | SAINT PETERSBURG | ||||||||
| State: | FL | ||||||||
| PostalCode: | 337051348 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7278941661 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/26/2021 | ||||||||
| LastUpdateDate: | 08/26/2021 | ||||||||
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| AuthorizedOfficialLastName: | PEREZ | ||||||||
| AuthorizedOfficialFirstName: | DWIGHT | ||||||||
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| AuthorizedOfficialTitleorPosition: | CREDENTIALING SPECIALIST | ||||||||
| AuthorizedOfficialTelephone: | 3057337513 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | INNOVACARE CENTRAL FLORIDA PHYSICIANS, LLC | ||||||||
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| NPICertificationDate: | 08/26/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.