MEDICARE: THE GOOD SHEPHERD MEDICAL CENTER 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	261QS1200X	Sleep Disorder Diagnostic Clinic/Center

General Provider Information

NPI Number	:	1861934721
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	THE GOOD SHEPHERD MEDICAL CENTER LLC

Provider Business Mailing Address
First Line	:	3080 E BAY DR
Second Line	:	SUITE 100
City	:	LARGO
State	:	FL
Zip	:	33771-2692
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	9119 RIDGE RD
Second Line	:	SUITE 4
City	:	NEW PORT RICHEY
State	:	FL
Zip	:	34654-5059
Country	:	US
Telephone Number	:	727-807-6969
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	SUMMER DEMETRIUS
Credential	:
Telephone Number	:	727-807-6969

Provider Enumeration Date	:	11/09/2016
Last Update Date	:	11/09/2016

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