Healthcare Provider Details

I. General information

NPI: 1902198948
Provider Name (Legal Business Name): WEST FLORIDA TRAUMA NETWORK, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/10/2011
Last Update Date: 10/15/2020
Certification Date: 10/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2010 59TH ST W SUITE 2200
BRADENTON FL
34209-4616
US

IV. Provider business mailing address

2000 HEALTH PARK DR
BRENTWOOD TN
37027-4525
US

V. Phone/Fax

Practice location:
  • Phone: 813-453-0590
  • Fax:
Mailing address:
  • Phone: 615-373-7600
  • Fax: 866-346-1426

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2086S0127X
TaxonomyTrauma Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: WILLIAM TEDRICK JOHNSON
Title or Position: GROUP VICE PRESIDENT/AO
Credential:
Phone: 615-372-3375