Basic Information
| Provider Information | |||||||||
| NPI: | 1316576705 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MORTON PLANT MEASE HEALTH SERVICES INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2995 DREW ST FL 2 | ||||||||
| Address2: | |||||||||
| City: | CLEARWATER | ||||||||
| State: | FL | ||||||||
| PostalCode: | 337593012 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7272819065 | ||||||||
| FaxNumber: | 8136352613 | ||||||||
| Practice Location | |||||||||
| Address1: | 1840 MEASE DR STE 103 | ||||||||
| Address2: | |||||||||
| City: | SAFETY HARBOR | ||||||||
| State: | FL | ||||||||
| PostalCode: | 346956603 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7277256463 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/07/2020 | ||||||||
| LastUpdateDate: | 04/07/2020 | ||||||||
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| AuthorizedOfficialLastName: | GORKEN | ||||||||
| AuthorizedOfficialFirstName: | LYNDA | ||||||||
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| AuthorizedOfficialTitleorPosition: | VP, PATIENT FINANCIAL SERVICES | ||||||||
| AuthorizedOfficialTelephone: | 7272819202 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | MORTON PLANT MEASE HEALTH SERVICES, INC | ||||||||
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| AuthorizedOfficialCredential: | VP | ||||||||
| NPICertificationDate: | 04/07/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | PENDING | 05 | FL | MEDICAID |