Healthcare Provider Details

I. General information

NPI: 1225601560
Provider Name (Legal Business Name): GREATER TAMPA BAY PHYSICIAN SPECIALISTS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/23/2021
Last Update Date: 07/23/2021
Certification Date: 07/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2010 59TH ST W STE 1500
BRADENTON FL
34209-4649
US

IV. Provider business mailing address

2000 HEALTH PARK DR
BRENTWOOD TN
37027-4692
US

V. Phone/Fax

Practice location:
  • Phone: 941-896-4788
  • Fax:
Mailing address:
  • Phone: 615-372-5426
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number
License Number State

VIII. Authorized Official

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