Basic Information
| Provider Information | |||||||||
| NPI: | 1609950674 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | USCG AIR STATION CLEARWATER | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | USCG AIRSTATION CLEARWATER HEALTH SERVICES DIVISION | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 15100 RESCUE WAY | ||||||||
| Address2: | |||||||||
| City: | CLEARWATER | ||||||||
| State: | FL | ||||||||
| PostalCode: | 33762 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 15100 RESCUE WAY | ||||||||
| Address2: | |||||||||
| City: | CLEARWATER | ||||||||
| State: | FL | ||||||||
| PostalCode: | 33762 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7275351437 | ||||||||
| FaxNumber: | 7275354190 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/25/2006 | ||||||||
| LastUpdateDate: | 09/24/2012 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | PERRY | ||||||||
| AuthorizedOfficialFirstName: | WILLIAM | ||||||||
| AuthorizedOfficialMiddleName: | STANLEY | ||||||||
| AuthorizedOfficialTitleorPosition: | CLINIC ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 7275351437 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | CHIEF WARRANT OFFICE | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QH0100X | Y | Ambulatory Health Care Facilities | Clinic/Center | Health Service |
No ID Information.