Healthcare Provider Details

I. General information

NPI: 1568136083
Provider Name (Legal Business Name): SAMUEL MADDOX
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/07/2021
Last Update Date: 03/01/2024
Certification Date: 03/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3400 GULF TO BAY BLVD
CLEARWATER FL
33759-4514
US

IV. Provider business mailing address

3400 GULF TO BAY BLVD
CLEARWATER FL
33759-4514
US

V. Phone/Fax

Practice location:
  • Phone: 813-574-5200
  • Fax:
Mailing address:
  • Phone: 813-574-5200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367H00000X
TaxonomyAnesthesiologist Assistant
License NumberAA776
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: