MEDICARE: TAMPA BAY PREMIER OBGYN PLLC

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	207V00000X	Obstetrics & Gynecology Physician

General Provider Information

NPI Number	:	1811459563
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TAMPA BAY PREMIER OBGYN PLLC

Provider Business Mailing Address
First Line	:	2727 W DR MLK BLVD STE 630
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33607-6399
Country	:	US
Telephone Number	:	813-876-6000
Fax Number	:	813-872-7459

Provider Business Practice Location Address
First Line	:	2727 W DR MLK BLVD STE 630
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33607-6399
Country	:	US
Telephone Number	:	813-876-6000
Fax Number	:	813-872-7459

Authorized Official
Title or Position	:	MANAGER
Name	:	VICKIE GONZALEZ
Credential	:
Telephone Number	:	813-876-6000

Provider Enumeration Date	:	04/02/2019
Last Update Date	:	04/02/2019

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