MEDICARE: UNIVERSITY OF SOUTH FLORIDA, BOARD OF TRUSTEES

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	261QR1100X	Research Clinic/Center

General Provider Information

NPI Number	:	1588932990
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	UNIVERSITY OF SOUTH FLORIDA, BOARD OF TRUSTEES

Provider Business Mailing Address
First Line	:	4202 E FOWLER AVE STOP ADM147
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33620-8001
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	12901 BRUCE B DOWNS BLVD
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33612-4742
Country	:	US
Telephone Number	:	813-974-3336
Fax Number	:

Authorized Official
Title or Position	:	CONTROLLER
Name	:	MS. LINDA PETERSON
Credential	:
Telephone Number	:	813-974-6061

Provider Enumeration Date	:	12/13/2011
Last Update Date	:	12/13/2011

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