Healthcare Provider Details

I. General information

NPI: 1750366290
Provider Name (Legal Business Name): THOMAS R SYVERSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/07/2005
Last Update Date: 11/30/2020
Certification Date: 11/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7394 W GULF TO LAKE HWY
CRYSTAL RIVER FL
34429-7802
US

IV. Provider business mailing address

14918 N FLORIDA AVE
TAMPA FL
33613-1632
US

V. Phone/Fax

Practice location:
  • Phone: 904-475-2039
  • Fax:
Mailing address:
  • Phone: 813-931-0000
  • Fax: 813-264-6868

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License NumberME54040
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code2084P2900X
TaxonomyPain Medicine (Psychiatry & Neurology) Physician
License NumberME54040
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: