Basic Information
| Provider Information | |||||||||
| NPI: | 1437550084 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COMMUNITY HEALTH CENTER OF PINELLAS INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | COMMUNITY HEALTH CENTER AT ST PETERSBURG | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 10549 | ||||||||
| Address2: | |||||||||
| City: | ST PETERSBURG | ||||||||
| State: | FL | ||||||||
| PostalCode: | 337330549 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7278248181 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 612 DR MARTIN L KING ST N | ||||||||
| Address2: | |||||||||
| City: | ST PETERSBURG | ||||||||
| State: | FL | ||||||||
| PostalCode: | 33705 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7278248181 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/12/2014 | ||||||||
| LastUpdateDate: | 12/11/2019 | ||||||||
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| AuthorizedOfficialLastName: | DORSO | ||||||||
| AuthorizedOfficialFirstName: | ELODIE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 7278248100 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | COMMUNITY HEALTH CENTER OF PINELLAS INC | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 12/11/2019 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | 029565521 | 05 | FL | MEDICAID | 029565522 | 05 | FL | MEDICAID |