MEDICARE: SAGO SUPERIOR MANAGEMENT INC

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	363LA2200X	Adult Health Nurse Practitioner	9176677	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1811152366
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SAGO SUPERIOR MANAGEMENT INC

Provider Business Mailing Address
First Line	:	PO BOX 15485
Second Line	:
City	:	ST PETERSBURG
State	:	FL
Zip	:	33733
Country	:	US
Telephone Number	:	727-320-7879
Fax Number	:	727-865-3242

Provider Business Practice Location Address
First Line	:	3040 36TH AVE S
Second Line	:
City	:	ST PETERSBURG
State	:	FL
Zip	:	33712-3731
Country	:	US
Telephone Number	:	727-320-7879
Fax Number	:	727-865-3242

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MS. SAFIYA A GORDON
Credential	:	ARNP
Telephone Number	:	727-320-7879

Provider Enumeration Date	:	07/24/2008
Last Update Date	:	07/30/2008

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