Basic Information
| Provider Information | |||||||||
| NPI: | 1902184781 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SELECT PHYSICIANS ALLIANCE PL | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10002 PRINCESS PALM AVE STE 332 | ||||||||
| Address2: | |||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336198327 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8135717184 | ||||||||
| FaxNumber: | 8136544695 | ||||||||
| Practice Location | |||||||||
| Address1: | 10002 PRINCESS PALM AVE STE 332 | ||||||||
| Address2: | |||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 33619 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8135717184 | ||||||||
| FaxNumber: | 8136544695 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/28/2011 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| AuthorizedOfficialLastName: | WATTS | ||||||||
| AuthorizedOfficialFirstName: | SHERYL | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | COO | ||||||||
| AuthorizedOfficialTelephone: | 8135717184 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 237600000X | N | 193200000X MULTI-SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Audiologist-Hearing Aid Fitter | 261QH0700X | N | Ambulatory Health Care Facilities | Clinic/Center | Hearing and Speech | 207YX0007X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Otolaryngology | Plastic Surgery within the Head & Neck | 207YX0602X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Otolaryngology | Otolaryngic Allergy | 231H00000X | N | 193200000X MULTI-SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Audiologist | 235Z00000X | N | 193200000X MULTI-SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Speech-Language Pathologist | 207YX0901X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Otolaryngology | Otology & Neurotology | 207YX0905X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Otolaryngology | Otolaryngology/Facial Plastic Surgery | 208100000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | 225100000X | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 207YP0228X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Otolaryngology | Pediatric Otolaryngology | 207YS0012X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Otolaryngology | Sleep Medicine | 207YS0123X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Otolaryngology | Facial Plastic Surgery | 207Y00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Otolaryngology |
ID Information
| ID | Type | State | Issuer | Description | 004140000 | 05 | FL | MEDICAID | FM218B | 01 | FL | MEDICARE PTAN | OTHER |