Healthcare Provider Details

I. General information

NPI: 1720641574
Provider Name (Legal Business Name): TAMPA GENERAL MEDICAL GROUP INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/17/2019
Last Update Date: 12/11/2025
Certification Date: 12/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14131 METROPOLIS AVE STE 103
FORT MYERS FL
33912-4455
US

IV. Provider business mailing address

PO BOX 1289
TAMPA FL
33601-1289
US

V. Phone/Fax

Practice location:
  • Phone: 239-224-3501
  • Fax: 239-224-3525
Mailing address:
  • Phone: 813-821-8460
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code204F00000X
TaxonomyTransplant Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: PETER TRAVIS RIAD CHANG
Title or Position: VP CARE TRANSITIONS
Credential:
Phone: 813-821-8460