MEDICARE: GREATER TAMPA BAY PHYSICIANS PINELLAS, LLC

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	207Q00000X	Family Medicine Physician

General Provider Information

NPI Number	:	1629402359
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GREATER TAMPA BAY PHYSICIANS PINELLAS, LLC

Provider Business Mailing Address
First Line	:	1100 62ND AVE S
Second Line	:
City	:	ST PETERSBURG
State	:	FL
Zip	:	33705-5620
Country	:	US
Telephone Number	:	727-866-3166
Fax Number	:	727-864-4043

Provider Business Practice Location Address
First Line	:	1100 62ND AVE S
Second Line	:
City	:	ST PETERSBURG
State	:	FL
Zip	:	33705-5620
Country	:	US
Telephone Number	:	727-866-3166
Fax Number	:	727-864-4043

Authorized Official
Title or Position	:	AO/VP
Name	:	KEN GRIFFIN
Credential	:
Telephone Number	:	727-771-7591

Provider Enumeration Date	:	08/29/2013
Last Update Date	:	08/29/2013

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