Healthcare Provider Details

I. General information

NPI: 1275642100
Provider Name (Legal Business Name): THE REPRODUCTIVE MEDICINE GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/30/2006
Last Update Date: 05/31/2022
Certification Date: 05/31/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

612 MEDICAL CARE DR
BRANDON FL
33511-5937
US

IV. Provider business mailing address

5245 E FLETCHER AVE SUITE 1
TEMPLE TERRACE FL
33617-1126
US

V. Phone/Fax

Practice location:
  • Phone: 813-661-9114
  • Fax:
Mailing address:
  • Phone: 813-914-7304
  • Fax: 813-914-7314

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207VE0102X
TaxonomyReproductive Endocrinology Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207VE0102X
TaxonomyReproductive Endocrinology Physician
License Number60 909
License Number StateFL

VIII. Authorized Official

Name: SUSAN GUY
Title or Position: CHIEF OPERATING OFFICER
Credential:
Phone: 813-914-7304