Basic Information
| Provider Information | |||||||||
| NPI: | 1386700797 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | EXPRESS CARE OF TAMPA BAY, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6015 REX HALL LN | ||||||||
| Address2: | |||||||||
| City: | APOLLO BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 335722657 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8136410068 | ||||||||
| FaxNumber: | 8136453816 | ||||||||
| Practice Location | |||||||||
| Address1: | 6015 REX HALL LN | ||||||||
| Address2: | |||||||||
| City: | APOLLO BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 335722657 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8136410068 | ||||||||
| FaxNumber: | 8136453816 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/29/2006 | ||||||||
| LastUpdateDate: | 12/01/2011 | ||||||||
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| AuthorizedOfficialLastName: | RAHMAN | ||||||||
| AuthorizedOfficialFirstName: | KHAWAJA | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8136907589 | ||||||||
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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 | 207R00000X | ME0071027 | FL | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 207RC0200X | ME71027 | FL | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Critical Care Medicine | 207RC0200X | ME79013 | FL | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Critical Care Medicine | 207R00000X | ME0079013 | FL | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 10560801 | 01 | FL | CITRUS GROUP UC | OTHER | 608813300 | 01 | FL | DEPT OF LABOR FACILITY | OTHER | B903U | 01 | FL | BCBS GROUP UC | OTHER | DB9962 | 01 | FL | RR MCARE GROUP | OTHER | 269227900 | 05 | FL | MEDICAID |