MEDICARE: TRILLIUM MEDICAL GROUP OF FLORIDA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208D00000X	General Practice Physician

General Provider Information

NPI Number	:	1285835322
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TRILLIUM MEDICAL GROUP OF FLORIDA

Provider Business Mailing Address
First Line	:	PO BOX 23788
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33623-3788
Country	:	US
Telephone Number	:	800-750-8103
Fax Number	:	866-788-0863

Provider Business Practice Location Address
First Line	:	1843 COLLIER PKWY
Second Line	:
City	:	LUTZ
State	:	FL
Zip	:	33549-8718
Country	:	US
Telephone Number	:	800-750-8103
Fax Number	:	866-788-0863

Authorized Official
Title or Position	:	PRESIDENT
Name	:	BOBBY L COATES
Credential	:
Telephone Number	:	727-403-5221

Provider Enumeration Date	:	05/29/2007
Last Update Date	:	08/22/2020

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