Basic Information
| Provider Information | |||||||||
| NPI: | 1639369226 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GERRISH | ||||||||
| FirstName: | STEPHEN | ||||||||
| MiddleName: | T. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2605 W SWANN AVE | ||||||||
| Address2: | SUITE 600 | ||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336094039 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8138767073 | ||||||||
| FaxNumber: | 8138771277 | ||||||||
| Practice Location | |||||||||
| Address1: | 2605 W SWANN AVE | ||||||||
| Address2: | SUITE 600 | ||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336094039 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8138767073 | ||||||||
| FaxNumber: | 8138771277 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/30/2007 | ||||||||
| LastUpdateDate: | 02/17/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RI0008X | MD.200507 | LA | N | Allopathic & Osteopathic Physicians | Internal Medicine | Hepatology | 207RG0100X | ME 102564 | FL | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
ID Information
| ID | Type | State | Issuer | Description | 1049981 | 05 | LA | MEDICAID | 09588574 | 05 | MS | MEDICAID |