Basic Information
| Provider Information | |||||||||
| NPI: | 1811940885 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | NORSOPH | ||||||||
| FirstName: | ELLIS | ||||||||
| MiddleName: | B | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6983 E FOWLER AVE | ||||||||
| Address2: | |||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336171714 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8138996223 | ||||||||
| FaxNumber: | 8139858006 | ||||||||
| Practice Location | |||||||||
| Address1: | 3100 E FLETCHER AVE | ||||||||
| Address2: | |||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336134613 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8139716000 | ||||||||
| FaxNumber: | 8139858006 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/18/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | ME78399 | FL | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 51851 | 01 | FL | BCBS OF FL | OTHER |