Basic Information
| Provider Information | |||||||||
| NPI: | 1770594665 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FLORIDA BEHAVIORAL INSTITUTE PLC | ||||||||
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| OtherOrganizationName: | FLORIDA BEHAVIORAL MEDICINE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1100 CLEARWATER LARGO RD N | ||||||||
| Address2: | |||||||||
| City: | LARGO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 337704131 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7275186444 | ||||||||
| FaxNumber: | 7275812678 | ||||||||
| Practice Location | |||||||||
| Address1: | 1100 CLEARWATER LARGO RD N | ||||||||
| Address2: | |||||||||
| City: | LARGO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 337704131 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7275186444 | ||||||||
| FaxNumber: | 7275812678 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/10/2006 | ||||||||
| LastUpdateDate: | 12/10/2012 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | PATEL | ||||||||
| AuthorizedOfficialFirstName: | ASHOK | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | SECRETARY TREASURER | ||||||||
| AuthorizedOfficialTelephone: | 7275186444 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0804X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Child & Adolescent Psychiatry | 2084P0805X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Geriatric Psychiatry | 2084P0800X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | K3338 | 01 | FL | MEDICARE PTAN | OTHER |