Basic Information
| Provider Information | |||||||||
| NPI: | 1346212370 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BLUESTONE PHYSICIAN SERVICES SOUTHEAST LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | BLUESTONE PHYSICIAN SERVICES FLORIDA, LLC | ||||||||
| OtherOrganizationType: | 4 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10150 HIGHLAND MANOR DR STE 240 | ||||||||
| Address2: | |||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336109750 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8132591013 | ||||||||
| FaxNumber: | 8132540396 | ||||||||
| Practice Location | |||||||||
| Address1: | 10150 HIGHLAND MANOR DR STE 240 | ||||||||
| Address2: | |||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336109750 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8132591013 | ||||||||
| FaxNumber: | 8132540396 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/03/2006 | ||||||||
| LastUpdateDate: | 10/22/2020 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BERNARD | ||||||||
| AuthorizedOfficialFirstName: | DIANA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | OFFICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 8132591013 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | I | ||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 10/22/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208D00000X | 5374 | FL | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 015006200 | 05 | FL | MEDICAID | CK5239 | 01 | FL | RAILROAD MEDICARE | OTHER | 34388 | 01 | FL | BC/BS | OTHER |