Basic Information
| Provider Information | |||||||||
| NPI: | 1467541839 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SAI MEDICAL CENTER LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 24535 | ||||||||
| Address2: | |||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336234535 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7278232188 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3831 16TH ST N | ||||||||
| Address2: | |||||||||
| City: | ST PETERSBURG | ||||||||
| State: | FL | ||||||||
| PostalCode: | 337035601 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7275272139 | ||||||||
| FaxNumber: | 7275222832 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/12/2006 | ||||||||
| LastUpdateDate: | 03/05/2009 | ||||||||
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| AuthorizedOfficialLastName: | IYYUNNI | ||||||||
| AuthorizedOfficialFirstName: | RAMANUJACHARY | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7275272139 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 45551 | 01 | FL | BCBS | OTHER | CH7631 | 01 | FL | RR MCR LOC 2 | OTHER | CH7639 | 01 | FL | RR MCR LOC 1 | OTHER |