Basic Information
Provider Information | |||||||||
NPI: | 1538140967 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | ST ANTHONY'S PROFESSIONAL BUILDINGS AND SERVICES, INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | SA IMMEDIATE CARE | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | P O BOX 403795 | ||||||||
Address2: |   | ||||||||
City: | ATLANTA | ||||||||
State: | GA | ||||||||
PostalCode: | 303840001 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8138523272 | ||||||||
FaxNumber: | 8138523233 | ||||||||
Practice Location | |||||||||
Address1: | 900 CARILLON PKWY | ||||||||
Address2: |   | ||||||||
City: | ST PETERSBURG | ||||||||
State: | FL | ||||||||
PostalCode: | 337161115 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7275562662 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/11/2005 | ||||||||
LastUpdateDate: | 08/22/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | KYES | ||||||||
AuthorizedOfficialFirstName: | FORD | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 7278251074 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Specialist |   |
ID Information
ID | Type | State | Issuer | Description | 2607697-01 | 05 | FL |   | MEDICAID |