Healthcare Provider Details

I. General information

NPI: 1477179463
Provider Name (Legal Business Name): PHYSICIANS PROFESSIONAL ALLIANCE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/25/2020
Last Update Date: 07/06/2020
Certification Date: 07/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

519 MEDICAL OAKS AVE
BRANDON FL
33511-5961
US

IV. Provider business mailing address

519 MEDICAL OAKS AVE
BRANDON FL
33511-5961
US

V. Phone/Fax

Practice location:
  • Phone: 813-685-7995
  • Fax: 813-685-8802
Mailing address:
  • Phone: 813-685-7995
  • Fax: 813-685-8802

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. GOPAL S GRANDHIGE
Title or Position: TREASURER
Credential: MD
Phone: 813-684-6006