MEDICARE: DWIC OF TAMPABAY, 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	261QU0200X	Urgent Care Clinic/Center

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	CG6489	OTHER	FL	RR MEDICARE

General Provider Information

NPI Number	:	1972552099
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DWIC OF TAMPABAY, INC

Provider Business Mailing Address
First Line	:	423 FORTRESS BLVD
Second Line	:
City	:	MORGANTOWN
State	:	WV
Zip	:	26508-1351
Country	:	US
Telephone Number	:	304-225-2500
Fax Number	:	304-985-6350

Provider Business Practice Location Address
First Line	:	5015 E BUSCH BLVD
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33617-5303
Country	:	US
Telephone Number	:	813-985-2784
Fax Number	:	813-989-9129

Authorized Official
Title or Position	:	CONTRACT MANAGER
Name	:	JOY KIMBALL
Credential	:
Telephone Number	:	763-349-6740

Provider Enumeration Date	:	05/08/2006
Last Update Date	:	05/07/2024

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