Basic Information
| Provider Information | |||||||||
| NPI: | 1558907873 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | USCG CLINIC ST PETERSBURG | ||||||||
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| Mailing Information | |||||||||
| Address1: | 600 8TH AVE SE | ||||||||
| Address2: | |||||||||
| City: | ST PETERSBURG | ||||||||
| State: | FL | ||||||||
| PostalCode: | 337015030 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7275351437 | ||||||||
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| Practice Location | |||||||||
| Address1: | 600 8TH AVE SE | ||||||||
| Address2: | |||||||||
| City: | ST PETERSBURG | ||||||||
| State: | FL | ||||||||
| PostalCode: | 337015030 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7275351437 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/21/2019 | ||||||||
| LastUpdateDate: | 11/21/2019 | ||||||||
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| AuthorizedOfficialLastName: | FITZGERALD | ||||||||
| AuthorizedOfficialFirstName: | DEBRA | ||||||||
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| AuthorizedOfficialTitleorPosition: | HEALTH SYSTEMS SPECIALIST | ||||||||
| AuthorizedOfficialTelephone: | 7576284363 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM1100X | Y | Ambulatory Health Care Facilities | Clinic/Center | Military/U.S. Coast Guard Outpatient |
No ID Information.