Basic Information
| Provider Information | |||||||||
| NPI: | 1417944232 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | INTERNAL MED & NEPHROLOGY ASSOC INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4710 N HABANA AVE | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336147161 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8138908004 | ||||||||
| FaxNumber: | 8132909691 | ||||||||
| Practice Location | |||||||||
| Address1: | 4710 N HABANA AVE | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336147161 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8138908004 | ||||||||
| FaxNumber: | 8132909691 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/06/2005 | ||||||||
| LastUpdateDate: | 10/08/2015 | ||||||||
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| AuthorizedOfficialLastName: | NAVARRO | ||||||||
| AuthorizedOfficialFirstName: | JESUS | ||||||||
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| AuthorizedOfficialTitleorPosition: | PHYSICIAN | ||||||||
| AuthorizedOfficialTelephone: | 8138731016 | ||||||||
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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 | 174400000X | ME0057891 | FL | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 373322000 | 05 | FL | MEDICAID |