Basic Information
| Provider Information | |||||||||
| NPI: | 1679560486 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MANISCALCO | ||||||||
| FirstName: | BENEDICT | ||||||||
| MiddleName: | S | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 2727 W DR MARTIN LUTHER KING JR BLVD | ||||||||
| Address2: | SUITE 800 | ||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336076383 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8138730000 | ||||||||
| FaxNumber: | 8138733659 | ||||||||
| Practice Location | |||||||||
| Address1: | 2727 W DR MARTIN LUTHER KING JR BLVD STE 800 | ||||||||
| Address2: | |||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336076065 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8138730000 | ||||||||
| FaxNumber: | 8138733659 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/06/2005 | ||||||||
| LastUpdateDate: | 09/28/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 09/28/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | ME0014584 | FL | N | Other Service Providers | Specialist | 207RC0000X | ME14584 | FL | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | ME14584 | 01 | FL | STATE LICENSE# | OTHER | 060069442 | 01 | FL | RR MEDICARE | OTHER | 059148300 | 05 | FL | MEDICAID |